Government of Ontario: Ministry of Health and Long-Term Care

Health Care Programs Division
Application for a Licence to Establish or Maintain and Operate a Nursing Home
The Nursing Homes Act.

General Information (to be completed by owner of Nursing Home Business)

1. Licence

Present Licence Number
Date of Expiration

2. Nursing Home

Name of Nursing Home
Address
Telephone Number

Adults
Total bed capacity
Extended Care
Intermediate Care

Children
Total bed capacity
Extended Care
Intermediate Care

3. Is Applicant:

Is Applicant (1) Individual
(2) Partnership
(3) Company

4. Name(s) and address(es) of Applicant(s):

a) If an Individual or Partnership

i Name
Address
Telephone number

ii Name
Address
Telephone number

iii Name
Address
Telephone number

b) If a company: (Attach a copy of Certificate of Incorporation with names and personal addresses of designated officers and directors).

iii

Name
Address
Telephone number

5. Has the applicant, or any director or officer of the applicant, been convicted under any law of any country or state or province thereof, of a criminal offence or are there any proceedings now pending?

Has the applicant, or any director or officer of the applicant, been convicted under any law of
any country or state or province thereof, of a criminal offence or are there any proceedings now pending? No
Yes

If Yes, give full particulars and information whether a full pardon has been granted.

6. Does applicant own the Nursing Home premises?

Does applicant own the Nursing Home premises? / No
Yes

7. Name of Administrator

Name of Administrator
Personal Address personnelle
Telephone number

8. Has the Administrator been convicted under any law of any country or state or province thereof, of a criminal offence or are there any proceedings now pending?

Has the Administrator been convicted under any law of any country or state or
province thereof, of a criminal offence or are there any proceedings now pending? No Yes

If yes give full particulars and information whether a pardon has been granted.

Please complete reverse side

9. Name of Advisory Physician

Name of Advisory Physician
Address
Telephone number

Agreement Written

10. Name of Emergency Physician

Name of Advisory Physician
Address
Telephone number

Agreement Written
Verbal

11. Staff

(A) Registered Nurses, Director

Name
Registration number
Hours worked per week

(B) Registered Nursing Assistants

Name
Registration number
Hours worked per week

(C) Health Care Aides, Director

Name
Hours worked per week

Other Members of the Staff

Name
Hours worked per week

Name
Hours worked per week

12.

(A) Dietitian

Dietitian
Registration number
Hours worked per week

Cooks

Cooks
Registration number
Hours worked per week

Kitchen helpers

Kitchen helpers
Registration number
Hours worked per week

(B) Housing (Kaundry, Maintenance, Cleaning, etc.)

Housing (Kaundry, Maintenance, Cleaning, etc.)
Registration number
Hours worked per week

(C) Pharmacist

Pharmacist
Registration number
Hours worked per week

(D) Activity Director

Activity Director
Registration number
Hours worked per week

(E) Other

Other
Registration number
Hours worked per week

Do you admit as residents, persons eligible for admission to a licensed Nursing Home under The Homes for Special Care Act, 1970 and the Regulation made thereunder?

Do you admit as residents, persons eligible for admission to a licensed Nursing Home
under The Homes for Special Care Act, 1970 and the Regulation made thereunder? No
Yes
Number of Residents

Signature(s) of Applicant(s), if an incorporated company, signature of the President and Secretary.

______________________________________________

Date

1668-69 (01/04)