CHT Renewal Application

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*	Date of application
*	Type of application
FACILITY INFORMATION
*	Legal name of facility
*	AKA or DBA name (N/A if not applicable)
*	Street address
*	City, State and Zip Code
*	Telephone number
*	Name of corporate or owner
*	Mailing address of owner (Street address or P.O. Box)
*	City, State and Zip Code
*	Name of facility Manager/Administrator
*	Telephone number of Manager/Administrator
*	Email address of Manager/Administrator
*	Name of Nurse Educator
*	Nurse Educator license number
*	Telephone number of Nurse Educator
*	Email address of Nurse Educator
*	Name of Medical Director
*	New Mexico Department of Health license number
*	Expiration date of current DOH license number
*	Date of last Board of Nursing survey (N/A if not applicable)
*	Does the program utilize Clinical Preceptors?	YES NO
AKNOWLEDGEMENTS AND ATTESTATION
*	Are there sufficient resources available to meet the needs and purpose of the program?	YES NO
*	I understand that 16.12.4.13 NMAC requires that certain program changes must be reported to the Board of Nursing for approval.	I agree
*	I affirm that the information provided is true and accurate. I understand the application is not complete until the application fee has been paid.	I agree
*	Submitted By: Name
*	Title
*	Date

FACILITY INFORMATION