Medication Aide Program Notification of Change of Administrator/Director/Owner

Medication Aide Program Notification of Change of Administrator/Director/Owner

Medication Aide Programs must notify the Board of Nursing of changes in ownership, administration, or nursing leadership.
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What kind of change would you like to report?

New Administrator/Director Information
Effective Date of Change

MonthDayYear
Date
Is this interim coverage for an administrative or nursing leadership position?
Interim Coverage Start Date
Expected Interim Coverage End Date
Name of New Administrator/Director

First NameLast Name
Job Title
New Administrator/Director Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
New Administrator/Director Email
example@example.com

New Ownership Information
Name of New Owner
New Owner Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Name of Facility
Previous Name of Facility
Previous Owner of Facility
Effective Date of Change of Ownership

MonthDayYear
Date
Upload an updated organizational chart that includes and identifies the current facility and medication aide program.

Cancelof
Upload the New Mexico Department of Health operator's license that identifies the facility

Cancelof
Does the facility intend to maintain the current approved medication aide program including the program curriculum?
Does the facility intend to maintain the current board approved medication aide program nurse educator?

Nursing Educator Information

Please provide the Nurse Educator information below. All fields must be completed, even if the information has not changed.
Nurse Educator Name

First NameLast Name
Nurse Educator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nurse educator email address
example@example.com
This Form was Submitted by

First NameLast Name
Title / Position
Email Address
example@example.com
By signing below and submitting this form, you certify that all information and documentation provided is true, complete, and accurate to the best of your knowledge. You understand that your electronic signature is the legal equivalent of your handwritten signature and is legally binding. You acknowledge that the New Mexico Board of Nursing may rely upon the information submitted and that providing false, misleading, or incomplete information may result in denial of the request or other action as permitted by law.
Signature
Should be Empty:

New Administrator/Director Information