Healthcare Branch Board of Examiners of Nursing Home Administrators

This is to certify that___________________________________________________________________________ (Applicant Name)

(Date of Birth)

was working in ________________________________ of ______________________________ (Type of Facility: Nursing Home/Hospital/Other-explain)

(Facility Name)

in the following capacity _________________________________________________________ (Nursing Home Administrator/DON/Other-explain)

I have attached a job description for the above named individual. The above named practiced for ___________ hours per week, from _____________ to (mm/dd/yy)

_____________. (mm/dd/yy)

Place of Employment: Address ______________________________________________________________________________ (Number and Street)

______________________________________________________________________________ (City, State, Zip)

I certify that all statements made on this form are true, complete and correct to the best of my knowledge and belief and are made in good faith. ____________________________________ Employer’s Signature

___________________________________ Employer’s Title/Position

____________________________________ Type or print Name

____________________________________ Date

Applicant: You must submit a separate Verification of Experience form for each place of employment and for each job title you wish to have considered.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.2988 F 303.894.7764 www.dora.colorado.gov/professions