Kan. Admin. Regs. § 112-3-4 - Application form for facility owner applicant
(a) Each
application for a facility owner license shall contain the following
information:
(1) The name of the applicant,
the business address and telephone number or numbers;
(2) the name, address and telephone number of
any individual who assisted the applicant in preparing its application along
with a precise description of the application section for which the individual
provided assistance;
(3) verified
responses regarding the following subjects in the order they appear below:
(A) Business structure and control of
applicant information required by K.A.R. 112-3-8;
(B) site and physical plant information
required by K.A.R. 112-3-9;
(C)
financing and development information required by K.A.R. 112-3-10; and
(D) economic, demographic and
other information required by K.A.R. 112-3-13;
(4) irrevocable affidavit and consent
statements; information waivers; affidavits relating to substance addiction;
waivers of claims for damages for adverse public notice, embarrassment,
criticism or other circumstance including financial loss that may result from
commission action on the application; and personal background disclosure forms
from all officers, directors, employees and agents of the applicant;
(5) copies of each contract and agreement
that the applicant has executed or proposes to execute and any modification or
proposed modification of each contract or agreement. If the contract or
agreement is an oral one, a written statement explaining the substance of the
oral agreement shall be included; and
(6) the names and addresses of the parties to
any contract or agreement identified in paragraph (5) and the relationship to
the applicant, the partners, associates, officers, directors and principal
owners either through family, business association or other control.
(b) Each exhibit, statement,
report, paper or other document submitted in support of the application shall
be current, accurate and complete. The applicant shall report immediately any
change in information submitted to the commission during the period of
application or licensure. At all times, a current copy of the documents
supporting the application shall be recorded in the commission office.
(c) This regulation shall take
effect on and after October 1, 1988.
Notes
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