MS Board of Nursing Home Administrators
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CONTINUING EDUCATION APPROVAL REQUEST FORM




Submit this request at least thirty (30) days prior to presentation of the program. In order to be eligible for approval, the program(s) must be open to all administrators and must relate to nursing home administration (See the Domains of Practice).

Sponsors are responsible for monitoring attendance and furnishing each participant with evidence of attendance.

Session will timeout after 45 minutes.
Name and address of requesting sponsor:
   
*Sponsor
*Address
Address 2
*City
*State
*Zip
*Email
*Program Title
Provide the phone number and web site address, if available, to be published on our web site for individuals wanting to register for the program.
*Phone   Ext. 
Web Address www.
*Total Program Education Hours:
Check the boxes below to select which of the following items are displayed on the MSNHA web site:
       
   
Program Coordinator:
*First Name
*Last Name
*Phone   Ext.:
*Is this program open to all licensed administrators?    


For approval, please specify where this program falls within the Domains of Practice by checking all that apply.

Upload a document that contains all documents showing the description of the program and the program agenda.



UPON COMPLETION OF THE PROGRAM, THE SPONSOR IS RESPONSIBLE FOR SUBMITTING A TYPED LIST OF PARTICIPANTS (IN ALPHABETICAL ORDER), ALONG WITH A PHOTOCOPY OF THE SIGN-IN SHEET(S), TO THE BOARD OFFICE


When you have completed the information above,
click Continue to enter the dates and locations on the next screen.

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MS Board of Nursing Home Administrators Website Disclaimer
1755 Lelia Drive Suite 305 Jackson, MS 39216
Office: (601) 362-6914
Fax: (601) 362-6925
Transparency Mississippi Management and Reporting System

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