MONTANA BOARD OF PUBLIC ACCOUNTANTS

Size: px
Start display at page:

Download "MONTANA BOARD OF PUBLIC ACCOUNTANTS"

Transcription

1 MONTANA BOARD OF PUBLIC ACCOUNTANTS 301 South Park 4 th Floor PO Box Helena Mt Phone: E mail: Website: APPLICATION FOR ORIGINAL LICENSE GENERAL INFORMATION The Application for Original License is for Montana exam candidates that have successfully passed the CPA exam and are applying for first time licensure; it is also for those that have been licensed in Montana previously and let their license terminate, and are not licensed in another jurisdiction. To obtain a License, you must have passed all sections of the exam and meet the education and experience requirements. An individual may not hold out as a CPA to the public without an active license. There is no residency requirement and a social security number is not required to obtain a license. If you do not have a social security number, you will need to complete the affidavit stating such and submit a notarized copy with your application. Individuals must have an active license to practice public accounting in Montana. See below for the definition of the practice of public accounting according to (10), MCA. "Practice of public accounting" means performing or offering to perform, by a person certified under , MCA; licensed under , MCA; or holding a practice privilege under , MCA for a client or potential client one or more types of services involving the use of accounting or auditing skills, including: (a) the issuance of reports or financial statements on which the public may rely; (b) one or more types of management advisory or consulting services; (c) the preparation of tax returns; or (d) furnishing advice on tax matters. All applications are reviewed by the Board at their regularly scheduled board meetings. A COMPLETED application must be received by the board 15 business days prior to a scheduled board meeting to be included on that meeting agenda. Please refer to our website for board meeting dates. The schedule of board meetings can be found under the Board Information/Board Meeting tab on the website. Applicants are responsible for providing all required documentation to the Board. Applications not completed within 12 months of applying are considered invalid and void. A new application and fee will be required in order to reapply.

2 LICENSE REQUIREMENTS 1. Application for Original License: Submit application and fee. You may not fax or scan and the application. We must receive either an online application or the original paper application. We must receive the following original supporting documents from the source, or from CPAES: Examination scores and results College or university transcripts (NIES evaluation document for foreign education) License verifications from other jurisdictions (If every held any professional license in a jurisdiction) Evidence of experience form 2. Professional Ethics: The AICPA Comprehensive Course: Complete the AICPA Comprehensive Ethics course. To order the self study course, go to The course is required whether you are applying for a certificate only or a permit to practice. 3. Verification: If you have ever held, or currently hold a professional license other than a CPA license, you must provide a license verification from all states where the professional license was/is held. 4. NASBA International Evaluation Services (NIES): An applicant with foreign qualifications will be required to have their foreign educational credentials evaluated in accordance with Montana s educational requirements by the NISE. The application form and pertinent information may be obtained from the NIES website at While the Board is not bound by the evaluation report, it is a guideline in determining if Montana s educational requirements have been met. 5. Education Requirement: A Montana exam applicant must meet the education requirement according to ARM Official transcripts must be provided from every university or college attended. 6. Experience Required For a License: An applicant applying for a License must submit the form entitled, "Evidence of Satisfaction of Experience Requirements" in accordance with ARM ARM provides that to be issued an initial License, an applicant must provide evidence of adequate accounting and auditing experience. Experience will be considered adequate by the Board if satisfactory evidence is presented of having performed accounting and auditing functions ordinarily required in the practice of public accounting. One year of actual work experience (2000 hours) is required. Experience must be attested to by a holder of an active license to practice public accounting in one of the 55 US jurisdictions unless you are using military experience. Experience must take place within the three (3) years prior to the date of this application. The US CPE must have a current license at the time of the attestation. The individual does not need to be a supervisor, but must be familiar with your work and able to attest that it meets professional standards.

3 MONTANA BOARD OF PUBLIC ACCOUNTANTS 301 South Park 4 th Floor PO Box Helena Mt Phone: E mail: Website: APPLICATION FOR ORIGINAL LICENSE License Fee: $ FULL NAME: Last First Middle OTHER NAME(S) KNOWN BY: BUSINESS NAME: BUSINESS ADDRESS: HOME ADDRESS: Street or PO Box # City and State Zip Country Street or PO Box # City and State Zip Country The Board s primary method of communication with licensees is . Include your preferred address: E MAIL: CHECK ONE: MALE FEMALE TELEPHONE: Business Home/Cell (please indicate) Fax U.S. SOCIAL SECURITY NUMBER: FOREIGN ID NUMBER DATE OF BIRTH: LICENSE NAME: PLACE OF BIRTH (State your name as it should appear on the license if granted) City / State/Country EDUCATION: Name of University or College City, State, Country Dates Attended Degree Earned

4 PROFESSIONAL LICENSES: List all professional licenses you hold or have ever held. License verifications must be sent directly to Montana from each jurisdiction. Attach additional sheets if necessary. Jurisdiction License # License Type Date Issued Expiration Date License Status Requested State Verification YES YES YES NO NO NO Disciplinary Questions: Please read carefully and answer questions completely and truthfully, it may affect your license. If you answer yes to any question, please attach a detailed explanation and provide supporting documentation from the source. Please circle the appropriate response. 1. Have you ever had an application for a professional or occupational license refused or YES NO denied?. 2. Have you ever withdrawn an application for licensure prior to licensing agency s YES NO decision regarding your application? 3. Has a licensing agency initiated or completed disciplinary action against any YES NO professional or occupational license you held? If yes, please provide the agency documentation including the complaint, initiating documents, orders, final orders, stipulations, and consent and/or settlement agreements directly from the source. 4. Have you ever voluntarily surrendered, cancelled, forfeited, failed to renew a YES NO professional or occupational license in anticipation of or during an investigation or disciplinary proceeding or action? 5. Has a complaint ever been made against you with a professional or occupational YES NO licensing agency? 6. Have any civil proceeding been filed against you by a client, former client or YES NO employer/employee? 7. Do you have any criminal charges pending or have you ever pled guilty, forfeited bond, YES NO or been convicted for a crime (whether or not sentence was suspended or deferred), or have you pled no contest or had prosecution deferred whether or not an appeal is pending? You must report, but may omit documentation for (1) misdemeanor traffic violations resulting In fines of less than $100; and (2) charges or convictions prior to your 18 th birthday unless You were tried as an adult.

5 8. Have you ever been diagnosed with chemical dependency or another addiction, or have YES NO you participated in a chemical dependency or other addiction treatment program? If yes, Please attach a detailed explanation and provide documentation regarding evaluations, diagnosis, treatment recommendations and monitoring from the source. 9. Have you ever been diagnosed with a physical condition or mental health disorder YES NO Involving potential health risk to the public? 10. Have you ever been court martialed or discharged other than honorably from a branch YES NO of the armed service? AFFIDAVIT I authorize the release of information concerning my education, training, record, character, license history and competence to practice, by anyone who might possess such information, to the Montana Board of Public Accountants. I understand that I am responsible for providing all of the necessary documentation to demonstrate my qualifications for licensure and the Board is not responsible for obtaining the necessary documentation. I understand that if my application is not complete, including all documentation, within 12 months of filing the application it will be invalid and void. A new application and fee will be required in order to reapply. I hereby declare under penalty of perjury the information included in my application to be true and complete to the best of my knowledge. In signing this application, I am aware that a false statement or evasive answer to any question may lead to denial of my application or subsequent revocation of licensure on ethical grounds. I have read and will abide by the current licensure statutes and rules of the State of Montana governing the profession. I will abide by the current laws and rules that govern my practice. Legal Signature of Applicant Date

6 THIS FORM ONLY BE USED FOR PERSONS/APPLICANTS/LICENSEES WHO DO NOT HAVE A SOCIAL SECURITY NUMBER STATE OF MONTANA BOARD OF PUBLIC ACCOUNTANTS REQUEST FOR EXEMPTION FROM SOCIAL SECURITY NUMBER REQUIREMENT Montana Code Annotated requires applicants for a Montana professional or occupational practice license to provide a United States Social Security Number (SSN). However, pursuant to Policy Interpretation Question (PIQ) number issued by the U.S. Dept. of Health and Human Services in 1999, the State of Montana, Department of Labor & Industry, Business Standards Division (BSD) may issue a license to an applicant who does not have a SSN if the applicant submits this form truthfully attesting that he or she has not been assigned a SSN. If a person (who has been issued a Montana practice license without a SSN) is later assigned a SSN, the person must report the SSN to the licensing board or program within BSD as a prior condition for renewal of licensure. If a person has already been issued a Montana practice license without having submitted a SSN or this affidavit at the time of original application, the person will be required to provide a SSN or this affidavit as a prior condition of renewal. All persons who do not have a SSN and who are applying for a new practice license from BSD or renewing an existing practice license must have filed a copy of this form with the BSD licensing board or program. The form need only be filed once for each license. THIS FORM MAY ONLY BE USED FOR PERSONS/APPLICANTS/LICENSEES WHO DO NOT HAVE A SOCIAL SECURITY NUMBER. If such a person has ever been issued a SSN, the person MUST provide it as a condition of licensing. A practice license will not be renewed or issued to a person who refuses to provide their SSN. 1. Name: Last /Family First Middle 2. Mailing Address: Street City State/Province Zip/Postal Code 3. Check one: I am applying for Montana license as a Public Accountant. I currently hold a Montana license as a Public Accountant. License #:. 4. I certify that I have not been assigned a U.S. Social Security Number. Yes No An answer of No to this question # 4 will result in a denial of your license application or renewal unless you provide the SSN. If you already have a SSN, you do not need to use this form. Instead, you must provide the SSN. 5. If a SSN is assigned to you after the date of this affidavit, do you agree to immediately report the SSN to the State of Montana, Department of Labor & Industry, Business Standards Division? Yes No An answer of No to this question # 5 will result in a denial of your license application or renewal.

7 AFFIDAVIT I, being first sworn, depose and affirm or state under penalty of perjury/falsification under the laws of Montana that that the information contained herein is true and correct to the best of my knowledge. I understand that under Montana law, providing false information is grounds for denial, suspension, or revocation of a professional or occupational license, certificate or permit and is also grounds for criminal prosecution. Signature: Date: This form must be notarized below. SUBSCRIBED AND SWORN TO before me before this day of, 20. Notary Public for the State of SEAL My commission Expires:

8 EXPERIENCE INSTRUCTIONS If you currently hold a certificate by the Montana Board of Public Accountants and are applying for an initial license, please include your Montana certificate number on the front of the form. ARM provides that to be issued an initial license, an applicant must provide evidence of adequate accounting and auditing experience. Experience will be considered adequate by the Board if satisfactory evidence is presented of having performed accounting and auditing functions ordinarily required in the practice of public accounting. One year of actual work experience (2000 hours) is required. Experience must be attested to by a holder of an active license to practice public accounting in one of the 55 Board jurisdictions unless you are using military experience. The US CPA attesting to your experience does not need to be a supervisor, but must be familiar with your work and able to attest that it meets professional standards. Experience must take place within three (3) years prior to the date of this application. However, individuals applying for licensure transfer according to ARM (3) must report four (4) years of experience in the practice of public accounting within the ten (10) years immediately preceding this application in order for the education requirement to be waived. Or, if applying using military experience and no U.S. CPA can attest to the experience, the applicant s commanding officer must provide sufficient information on the duties and responsibilities of the applicant for the Board to evaluate to determine if the applicant meets the 2000 hour experience requirement.

9 MONTANA BOARD OF PUBLIC ACCOUNTANTS 301 South Park PO Box Helena Mt Phone: E mail: Website: EVIDENCE OF SATISFACTION OF EXPERIENCE REQUIREMENTS FORM FULL NAME: Last First Middle MONTANA CERTIFICATE # (IF PREVIOUSLY HELD): OTHER NAME(S) KNOWN BY: EMPLOYER NAME: EMPLOYER ADDRESS: Street or PO Box # City and State Zip Country POSITION TITLE OF APPLICANT: TYPE OF ACCOUNTING EMPLOYMENT: PUBLIC GOVERNMENTAL PRIVATE INDUSTRY ACADEMIC PERIOD OF EMPLOYMENT: Only list employment within the previous 3 years (4 of the past 10 years if applying under ARM (3). See Experience instructions.) FULL TIME: FROM TO TOTAL HOURS: MONTH/DAY/YEAR MONTH/DAY/YEAR PART TIME: FROM TO TOTAL HOURS: MONTH/DAY/YEAR MONTH/DAY/YEAR ATTESTATION NAME PHONE NO POSITION RELATIONSHIP TO APPLICANT NATURE AND LEVEL OF WORK PERFORMED BY APPLICANT (ATTACH ADDITIONAL SIGNED SHEETS AS NECESSARY): I hold an active license (# ) to practice public accounting in the State of, which expires on. I certify under penalty of perjury that I have reviewed the applicant s work, this completed form and any attachments, and that the information is correct. SIGNATURE DATE

Applicants will be notified within 15 working days of receipt of a completed application as to the status of the application.

Applicants will be notified within 15 working days of receipt of a completed application as to the status of the application. 2/09, 03/11, 11/11, 01/13, 01/15 Page 1 of 10 MONTANA BOARD OF RADIOLOGIC TECHLOGISTS 301 SOUTH PARK, 4TH FLOOR PO BOX 200513 HELENA, MONTANA 59620-0513 (406) 841-2202 FAX: (406) 841-2305 email: dlibsdrts@mt.gov

More information

**Make check or money order payable to the Montana Board of Barbers and Cosmetologists**

**Make check or money order payable to the Montana Board of Barbers and Cosmetologists** Page 1 of 5 MONTANA BOARD OF BARBERS AND COSMETOLOGISTS P. O. Box 200513 301 S PARK, 4 TH FLOOR (Delivery) Helena, Montana 59620-0513 (406) 841-2202 FAX (406) 841-2309 E-MAIL: dlibsdcos@mt.gov WEBSITE:

More information

TECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION

TECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION Page 1 of 8 MONTANA BOARD OF PHARMACY (301 S PARK, 4 TH FLOOR, HELENA, MT 59601 - Delivery) P. O. Box 200513 Helena, Montana 59620-0513 PHONE (406) 841-2300 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov

More information

INSTRUCTIONS FOR AN APRN LICENSE: (This application is for APRN practice. A separate application is needed for Prescriptive Authority.

INSTRUCTIONS FOR AN APRN LICENSE: (This application is for APRN practice. A separate application is needed for Prescriptive Authority. Page 1 of 9 MONTANA BOARD OF NURSING PO Box 200513 (301 S Park, 4th Floor) Helena, MT 59620-0513 LICENSING PHONE: (406) 841-2202 FAX: (406) 841-2305 EMAIL: nurse@mt.gov WEBSITE: www.nurse.mt.gov INSTRUCTIONS

More information

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS

More information

APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR DENTAL HYGIENE

APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR DENTAL HYGIENE Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR

More information

APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY

APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY Minnesota Board of Marriage and Family Therapy 2829 University Avenue SE, Suite 400 Minneapolis, MN 55414-3222 Telephone: (612) 617-2220 Fax: (612) 617-2221 Email: mft.board@state.mn.us Website: www.bmft.state.mn.us

More information

ACCOUNTING PRACTITIONER LICENSING REQUIREMENTS

ACCOUNTING PRACTITIONER LICENSING REQUIREMENTS ACCOUNTING PRACTITIONER LICENSING REQUIREMENTS 1. No prior history of dishonest or felonious acts: 2. Be a resident of this State or have a place of business in this State, or as an employee, be regularly

More information

Montana Application for Class 6 Specialist License School Psychologist Endorsement

Montana Application for Class 6 Specialist License School Psychologist Endorsement Montana Application for Class 6 Specialist License School Psychologist Endorsement Requirements for Montana Class 6 School Psychologist Specialist license 1. Verification of current credentials as a nationally

More information

New Mexico Regulation and Licensing Department

New Mexico Regulation and Licensing Department New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION Board of Social Work Examiners PO Box 25101 Santa Fe, New Mexico 87504 (505) 476-4890 Fax (505) 476-4620 www.rld.state.nm.us

More information

PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made

PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made available to any person upon request. This application

More information

MINNESOTA BOARD OF PHYSICAL THERAPY

MINNESOTA BOARD OF PHYSICAL THERAPY Telephone 612-627-5406 Fax 612-627-5403 PHYSICAL THERAPY BOARD PHYSICAL THERAPIST ASSISTANT FACT SHEET The Physical Therapy Board is appointed by the Governor to act on issues regarding physical therapist

More information

CERTIFIED PUBLIC ACCOUNTANT

CERTIFIED PUBLIC ACCOUNTANT STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE CERTIFIED PUBLIC ACCOUNTANT APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division of

More information

APPLICATION PACKET PSYCHOLOGIST LICENSE BY CREDENTIALS

APPLICATION PACKET PSYCHOLOGIST LICENSE BY CREDENTIALS Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Juneau, Alaska 99811-0806 Telephone: (907) 465-5470 E-mail: license@alaska.gov

More information

Application for New Louisiana Pharmacy Technician Candidate Registration

Application for New Louisiana Pharmacy Technician Candidate Registration Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70809-1700 Telephone 225.925.6496 ~ Facsimile 225.925.6499 www.pharmacy.la.gov ~ E-mail: info@pharmacy.la.gov Application for New

More information

South Dakota Board of Nursing Facility Administrators P.O. Box 340, 1351 N. Harrison Ave. Pierre, SD 57501-0340 Ph.: 605-224-1721 Fax: 888-425-3032

South Dakota Board of Nursing Facility Administrators P.O. Box 340, 1351 N. Harrison Ave. Pierre, SD 57501-0340 Ph.: 605-224-1721 Fax: 888-425-3032 South Dakota Board of Nursing Facility Administrators P.O. Box 340, 1351 N. Harrison Ave. Pierre, SD 57501-0340 Ph.: 605-224-1721 Fax: 888-425-3032 E-mail: SDNFA@midwestsolutionssd.com http://nursingfacility.sd.gov

More information

INFORMATION & INSTRUCTIONS FOR CPA CERTIFICATION BY RECIPROCITY

INFORMATION & INSTRUCTIONS FOR CPA CERTIFICATION BY RECIPROCITY INFORMATION & INSTRUCTIONS FOR CPA CERTIFICATION BY RECIPROCITY Reciprocity is the application for certification based on information provided to the Nevada board that you have met Nevada s requirements

More information

The University of the State of New York. THE STATE EDUCATION DEPARTMENT Office of the Professions

The University of the State of New York. THE STATE EDUCATION DEPARTMENT Office of the Professions The University of the State of New York Certified Public Accountant THE STATE EDUCATION DEPARTMENT Office of the Professions Form 1 Division of Professional Licensing Services www.op.nysed.gov Application

More information

M E M O R A N D U M. TO: ALL Interior Designer applicants FROM: JEAN WILLIAMS, EXECUTIVE DIRECTOR

M E M O R A N D U M. TO: ALL Interior Designer applicants FROM: JEAN WILLIAMS, EXECUTIVE DIRECTOR M E M O R A N D U M The Board of Governors of the Licensed Architects Landscape Architects and Registered Interior Designers of Oklahoma P. O. Box 53430 Oklahoma City, OK 73152 (405) 949-2383 TO: ALL Interior

More information

PART II. LICENSURE BY CREDENTIALS

PART II. LICENSURE BY CREDENTIALS State of Alaska P.O. Box 110806, Juneau, Alaska 99811-0806 Telephone: (907) 465-2551 E-mail: license@alaska.gov Website: www.commerce.alaska.gov/occ BACCALAUREATE SOCIAL WORKER LICENSURE APPLICATION READ

More information

PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made

PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made PUBLIC RECORD: This application is a public record for purposes of the Maine Freedom of Access Law (1 MRSA 401 et seq). Public records must be made available to any person upon request. This application

More information

BOARD OF CHIROPRACTIC MEDICINE GENERAL INFORMATION/INSTRUCTIONS REGISTERED CHIROPRACTIC ASSISTANT

BOARD OF CHIROPRACTIC MEDICINE GENERAL INFORMATION/INSTRUCTIONS REGISTERED CHIROPRACTIC ASSISTANT BOARD OF CHIROPRACTIC MEDICINE GENERAL INFORMATION/INSTRUCTIONS REGISTERED CHIROPRACTIC ASSISTANT HOW TO APPLY FOR FLORIDA LICENSURE *** PLEASE TYPE OR PRINT IN BLACK INK - PLEASE READ CAREFULLY *** 1.

More information

Licensure as a Pharmacy Technician

Licensure as a Pharmacy Technician *** Submit this page with application *** ***FOR OFFICE USE ONLY*** Receipt # ID # Issue Date License # State of Rhode Island Board of Pharmacy Room 205 3 Capitol Hill Providence, RI 02908-5097 Instructions

More information

INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT

INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT A. TEMPORARY LICENSE (90 DAYS)- Applicant must submit the following: Temporary licenses are valid for

More information

Maryland Insurance Administration Individual Producer License Renewal / Reinstatement Checklist

Maryland Insurance Administration Individual Producer License Renewal / Reinstatement Checklist Maryland Insurance Administration Individual Producer License Renewal / Reinstatement Checklist Important Update: The attached application and supplement may be used to renew or reinstate an existing Maryland

More information

Massachusetts Board of Registration in Pharmacy. Pharmacy Technician Registration Application

Massachusetts Board of Registration in Pharmacy. Pharmacy Technician Registration Application The Massachusetts Board of (Board) has contracted with Professional Credential Services (PCS) to process registration applications from pharmacy technicians. Applicants must submit all information directly

More information

Texas Board of Nursing 333 Guadalupe, Ste 3-460, Austin, TX 78701 Phone: 512-305-7400

Texas Board of Nursing 333 Guadalupe, Ste 3-460, Austin, TX 78701 Phone: 512-305-7400 For Office Use Only Date: Amount: Texas Board of Nursing 333 Guadalupe, Ste 3-460, Austin, TX 78701 Phone: 512-305-7400 PETITION FOR DECLARATORY ORDER Audit #: FBI HX: YES NO Complete this application

More information

APPLICATION INFORMATION FOR LICENSURE AS A REHABILITATION COUNSELOR

APPLICATION INFORMATION FOR LICENSURE AS A REHABILITATION COUNSELOR The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Allied Mental Health and Human Service Professions 1000 Washington Street, Suite 710 Boston, MA 02118-6100

More information

STEP 5 - EDUCATION You must request Official Transcripts verifying your education, to be sent directly from your college or university.

STEP 5 - EDUCATION You must request Official Transcripts verifying your education, to be sent directly from your college or university. INFORMATION & INTRUCTIONS FOR CPA CERTIFICATION This application is for CPA Licensure by Original Certification based on an applicant s passing the CPA Examination in another state. The applicant will

More information

**Additional information may be requested at the discretion of the Board.**

**Additional information may be requested at the discretion of the Board.** Oklahoma State Board of Dentistry 2920 N Lincoln Blvd., Ste. B OKC, OK 73105 (405)522-4844 Oklahoma State Board of Dentistry CHECKLIST- DDS/ SPECIALTY/ RDH BY CREDENTIALS *In order to be eligible for licensure

More information

Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 (502) 429-7150

Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 (502) 429-7150 Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 (502) 429-7150 M E M O R A N D U M TO: FROM: RE: Applicants for Surgical Assistant Certification Dawn Beahl, Surgical

More information

Carefully read the following instructions for completing the respiratory therapist license application.

Carefully read the following instructions for completing the respiratory therapist license application. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES DEPARTMENT OF PUBLIC HEALTH DIVISION OF HEALTH PROFESSIONS LICENSURE 239 CAUSEWAY STREET, SUITE 500, 5TH FLOOR, BOSTON, MA 02114

More information

CLINICAL SOCIAL WORKER LICENSURE APPLICATION

CLINICAL SOCIAL WORKER LICENSURE APPLICATION P.O. Box 110806, Juneau, Alaska 99811-0806 Telephone: (907) 465-2551 E-mail: license@alaska.gov Website: www.commerce.alaska.gov/occ CLINICAL SOCIAL WORKER LICENSURE APPLICATION READ THESE INSTRUCTIONS

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS

Vermont Board of Nursing INSTRUCTION TO APPLICANTS Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org INSTRUCTION TO APPLICANTS The following applies to applications

More information

INSTRUCTIONS FOR HEARING AID DISPENSING APPLICATION

INSTRUCTIONS FOR HEARING AID DISPENSING APPLICATION BOARDS AND COMMISSIONS DIVISION New Mexico Speech-Language Pathology, Audiology and Hearing Aid Dispensing Practices Board PO Box 25101 Santa Fe, New Mexico 87505 (505) 476-4640 Fax (505) 476-4620 www.rld.state.nm.us

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY NON-PROFIT CORPORATION PERMIT APPLICATION

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY NON-PROFIT CORPORATION PERMIT APPLICATION FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY N-PROFIT CORPORATION PERMIT APPLICATION Applications will be accepted only if completed by an officer of the non-profit organization. Any questions not applicable

More information

Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510

Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 APPLICATION FOR RECOGNITION TO ADMINISTER LOCAL ANESTHESIA

More information

OKLAHOMA ACCOUNTANCY BOARD ( OAB ) QUALIFICATION APPLICATION AND INSTRUCTIONS

OKLAHOMA ACCOUNTANCY BOARD ( OAB ) QUALIFICATION APPLICATION AND INSTRUCTIONS OKLAHOMA ACCOUNTANCY BOARD ( OAB ) QUALIFICATION APPLICATION AND INSTRUCTIONS Prior to completing and submitting the Qualification Application to the OAB, we suggest that you download the Eligibility Checklist

More information

Oklahoma Board of Dentistry

Oklahoma Board of Dentistry Susan Rogers, Esq. Executive Director Mary Fallin Governor Oklahoma Board of Dentistry HYGIENE APPLICATIONS BY EXAM APPLICATION PROCESS: 1. Submit a completed application; include the non-refundable fee

More information

APPLICATION INSTRUCTIONS FOR LICENSED ALCOHOL AND DRUG ABUSE COUNSELOR (LADAC)

APPLICATION INSTRUCTIONS FOR LICENSED ALCOHOL AND DRUG ABUSE COUNSELOR (LADAC) New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION Counseling and Therapy Practice Board PO Box 25101 Santa Fe, New Mexico 87505 (505) 476-4610 Fax (505) 476-4645 www.rld.state.nm.us

More information

CERTIFICATE OF AUTHORITY (COA) INSTRUCTIONS AND REQUIREMENTS FAQ S

CERTIFICATE OF AUTHORITY (COA) INSTRUCTIONS AND REQUIREMENTS FAQ S CERTIFICATE OF AUTHORITY (COA) INSTRUCTIONS AND REQUIREMENTS Eligibility for a COA to practice as a Certified Nurse Midwife (CNM), Certified Nurse Practitioner (CNP), Certified Nurse Specialist (CNS) or

More information

30 Day Limited Permits for Professional Engineers and Land Surveyors

30 Day Limited Permits for Professional Engineers and Land Surveyors THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of the Professions, State Board for Engineering and Land Surveying PHONE: 518-474-3817 ext. 140 FAX: 518-473-6282

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE. LICENSE BY ENDORSEMENT Applicant must submit the following:

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE. LICENSE BY ENDORSEMENT Applicant must submit the following: Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-2396 www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Certified Nurse Midwife APPLICANT INFORMATION Full Legal Name: First Middle Last All Previous Legal

More information

ARKANSAS BOARD OF PODIATRIC MEDICINE

ARKANSAS BOARD OF PODIATRIC MEDICINE ARKANSAS BOARD OF PODIATRIC MEDICINE APPLICATION FOR LICENSE TO PRACTICE PODIATRIC MEDICINE 1. Name: Social Security Number: (As to appear on License) 2. Address: 3. Address you wish License to be mailed:

More information

BOARD OF ACCOUNTANCY CPA LICENSE APPLICATION Required Fee: $ (includes criminal records check fee)

BOARD OF ACCOUNTANCY CPA LICENSE APPLICATION Required Fee: $ (includes criminal records check fee) State of Maine Department of Professional & Financial Regulation Office of Professional & Occupational Regulation INDIVIDUAL LICENSE APPLICATION APPLICANT INFORMATION (please print) FULL LEGAL NAME FIRST

More information

Applying on the Basis of Examination

Applying on the Basis of Examination Vermont Secretary of State, Board of Veterinary Medicine Montpelier, Vermont 05620-3402 PHONE: (802) 828-2373 FAX: (802) 828-2465 E-mail address: Aprille.Morrison@sec.state.vt.us Web site: www.vtprofessionals.org

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR TEACHING PERMIT Chapter 466.002, Florida Statutes Rule 64B5-7.005, Florida Administrative Code Applications will be accepted only if completed

More information

Last First Middle Date of Birth. City State Zip Code Country of Citizenship

Last First Middle Date of Birth. City State Zip Code Country of Citizenship North Dakota State Board of Accountancy CPA Exam Application 2701 S Columbia Road, Grand Forks ND 58201-6029 Phone 701-775-7100 or 800-532-5904 www.nd.gov/ndsba ndsba@nd.gov INSTRUCTIONS Please print neatly

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Veterinarian APPLICANT INFORMATION Full Legal Name: First Middle Last All Previous Legal Names:

More information

Application Letter of Instruction

Application Letter of Instruction STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX 34779 Reno, Nevada 89533-4779 (775) 746-4101 / Fax: (775) 746-4105 / Toll Free: (800) 431-2659 Email: board@nvot.org / Website: www.nvot.org TYPES

More information

Athletic Trainer License Application Methods

Athletic Trainer License Application Methods Athletic Trainer License Application Methods Please read carefully to determine the application method for which you are qualified Indicate the appropriate method on the application and submit the required

More information

Important information for Applicants and Supervisors:

Important information for Applicants and Supervisors: The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Allied Mental Health and Human Service Professions 1000 Washington Street, Suite 710 Boston, MA 02118-6100

More information

Appraisal Management Company (AMC)

Appraisal Management Company (AMC) REAL ESTATE APPRAISER LICENSING AND CERTIFICATION BOARD Appraisal Management Company (AMC) Application Packet July 30, 2013 APPLICATION FOR REGISTRATION OF AN APPRAISAL MANAGEMENT COMPANY INSTRUCTIONS

More information

Submission of the Criminal Offender Record Information Request Form (CORI).

Submission of the Criminal Offender Record Information Request Form (CORI). COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES DEPARTMENT OF PUBLIC HEALTH DIVISION OF HEALTH PROFESSIONS LICENSURE 239 CAUSEWAY STREET, SUITE 500, 5TH FLOOR, BOSTON, MA 02114

More information

BOARD OF REGISTRATION OF SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY Instructions for Speech-Language Pathologist License Application

BOARD OF REGISTRATION OF SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY Instructions for Speech-Language Pathologist License Application BOARD OF REGISTRATION OF SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY Instructions for Speech-Language Pathologist License Application 1. If you do not possess or are ineligible for a Social Security No., contact

More information

Board of Speech-Language Pathology and Audiology

Board of Speech-Language Pathology and Audiology Board of Speech-Language Pathology and Audiology Application for Speech-Language Pathology or Audiology Provisional Licensure With Instructions Attached Board of Speech-Language Pathology and Audiology

More information

LICENSING PROCEDURES FOR AUTOMOBILE CLUB AGENTS (MOTOR CLUB AGENTS)

LICENSING PROCEDURES FOR AUTOMOBILE CLUB AGENTS (MOTOR CLUB AGENTS) LICENSING PROCEDURES FOR AUTOMOBILE CLUB AGENTS (MOTOR CLUB AGENTS) Requirements for an Automobile Club (Motor Club) Agent License (1) Completed, signed and notarized application (2) $20.00 filing fee

More information

STATE BOARD OF ACCOUNTANCY

STATE BOARD OF ACCOUNTANCY REV 3-15a STATE BOARD OF ACCOUNTANCY MAILING ADDRESS COURIER ADDRESS PHONE 717-783-1404 STATE BOARD OF ACCOUNTANCY STATE BOARD OF ACCOUNTANCY FAX 717-705-5540 P.O. BOX 2649 2601 NORTH THIRD STREET E-MAIL

More information

Dietitian/Nutritionist Certification Application Packet

Dietitian/Nutritionist Certification Application Packet Dietitian/Nutritionist Certification Application Packet Contents: 1. 687-007... Contents List/SSN Information/Mailing Information...1 page 2. 687-009... Application Instructions Checklist...2 pages 3.

More information

APPLICATION FOR ADDICTION COUNSELOR TRAINEE RECOGNITION OR ADDICTION COUNSELOR TRAINEE RENEWAL

APPLICATION FOR ADDICTION COUNSELOR TRAINEE RECOGNITION OR ADDICTION COUNSELOR TRAINEE RENEWAL Board of Addiction and Prevention Professionals (BAPP) 3101 West 41 st Street, Suite 205, Sioux Falls, SD 57105 Phone: 605-332-2645 Fax: 605-332-6778 Email: bapp@midconetwork.com Web: www.dss.sd.gov/bapp

More information

Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing

Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing MED THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing State Medical Board PO Box 110806, Juneau, AK 99811-0806

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Psychologist APPLICANT INFORMATION Full Legal

More information

PLEASE READ BEFORE COMPLETING APPLICATION

PLEASE READ BEFORE COMPLETING APPLICATION PLEASE READ BEFORE COMPLETING APPLICATION Information for Licensure: SOCIAL WORKER (LSW) Each item on the enclosed application must be completed. Allow 30 days for processing of the application. Failure

More information

Athletic Trainer License Application Packet

Athletic Trainer License Application Packet Athletic Trainer License Application Packet Contents: 1. 644-001... Contents List/SSN Information/ Mailing Information...1 page 2. 644-002... Application Instructions Checklist... 3 pages 3. 644-003...

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR LIMITED LICENSURE DENTIST/DENTAL HYGIENIST

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR LIMITED LICENSURE DENTIST/DENTAL HYGIENIST Statute and Rule References: -Section 456.015, Florida Statutes -Rule 64B5-7.007, Florida Administrative Code APPLICATION FOR LIMITED LICENSURE DENTIST/DENTAL HYGIENIST General Requirements and Information

More information

STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS

STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS STATE OF FLORIDA BOARD OF ACUPUNCTURE APPLICATION FOR LICENSURE WITH INSTRUCTIONS Board of Acupuncture 4052 Bald Cypress Way, Bin # C-06 Tallahassee, FL 32399-3256 (850) 488-0595 September 2012 Edition

More information

COMMUNITY ASSOCIATION MANAGER APPLICATION FOR LICENSURE

COMMUNITY ASSOCIATION MANAGER APPLICATION FOR LICENSURE COMMUNITY ASSOCIATION MANAGER APPLICATION FOR LICENSURE ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION Division of Professional Regulation 320 West Washington Street, 3 rd Floor Springfield,

More information

Hypnotherapist Registration Application Packet

Hypnotherapist Registration Application Packet Hypnotherapist Registration Application Packet Contents: 1. 670-088...Contents List/SSN Information/Mailing Information...1 page 2. 670-053...Application Instruction Checklist... 2 pages 3. 670-052...Hypnotherapy

More information

Medical Assistant-Phlebotomist Certification Application Packet

Medical Assistant-Phlebotomist Certification Application Packet Medical Assistant-Phlebotomist Certification Application Packet Contents: 1. 651-007...Contents List/SSN Information/Mailing Information...1 page 2. 651-008...Application Instructions Checklist... 2 pages

More information

IOWA PLUMBING & MECHANICAL SYSTEMS BOARD

IOWA PLUMBING & MECHANICAL SYSTEMS BOARD IOWA PLUMBING & MECHANICAL SYSTEMS BOARD Contractor License Renewal Form Instructions Enclosed is an application for renewal of your Iowa Plumbing & Mechanical Systems Board contractor license. To expedite

More information

Psychology (Doctorate/Masters) Renewal/Reinstatement Application

Psychology (Doctorate/Masters) Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Psychological Examiners Renewal Clerk (802) 828-1505 www.vtprofessionals.org

More information

LICENSURE REQUIREMENTS

LICENSURE REQUIREMENTS MW - Instructions Rev 3/08, 2/09, 2/15 Page 1 of 12 MONTANA BOARD OF ALTERNATIVE HEALTH CARE 301 SOUTH PARK, 4th FLOOR PO BOX 200513 HELENA MONTANA 59620-0513 (406) 841-2203 FAX (406) 841-2305 EMAIL: dlibsdahc@mt.gov

More information

IOWA PLUMBING & MECHANICAL SYSTEMS BOARD INSTRUCTIONS FOR APPLICATION FOR CONTRACTOR LICENSES

IOWA PLUMBING & MECHANICAL SYSTEMS BOARD INSTRUCTIONS FOR APPLICATION FOR CONTRACTOR LICENSES IOWA PLUMBING & MECHANICAL SYSTEMS BOARD INSTRUCTIONS FOR APPLICATION FOR CONTRACTOR LICENSES Submit completed applications with a check or money order to: Iowa Plumbing and Mechanical Systems Board Iowa

More information

PHYSICAL THERAPIST AND PHYSICAL THERAPY ASSISTANT LICENSE APPLICATION PACKET

PHYSICAL THERAPIST AND PHYSICAL THERAPY ASSISTANT LICENSE APPLICATION PACKET THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Physical Therapy and Occupational Therapy State Office

More information

Medical Assistant-Certified or Interim Application Packet

Medical Assistant-Certified or Interim Application Packet Medical Assistant-Certified or Interim Application Packet Contents: 1. 651-015...Contents List/SSN Information/Mailing Information...1 page 2. 651-016...Application Instructions Checklist...2 pages 3.

More information

Licensed Clinical Mental Health Counselor Renewal/Reinstatement Application

Licensed Clinical Mental Health Counselor Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Allied Mental Health Renewal Clerk (802) 828-1505 www.vtprofessionals.org

More information

OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST

OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement:

More information

APPRAISAL MANAGEMENT COMPANY RENEWAL APPLICATION

APPRAISAL MANAGEMENT COMPANY RENEWAL APPLICATION Complete, sign, and submit this form along with the items listed below to the Division. Entity Name: Email: Business Address: City: State: Zip: Ph: Fax: Registered Agent: Email: City: State: Zip: Ph: Fax:

More information

Registered OR- Certified Public Accountant Renewal/Reinstatement Application

Registered OR- Certified Public Accountant Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Accountancy Board Renewal Clerk (802) 828-1505 www.vtprofessionals.org

More information

X-Ray Technician Limited Scope Registration Application Packet

X-Ray Technician Limited Scope Registration Application Packet X-Ray Technician Limited Scope Registration Application Packet Contents: 1. 686-046... Contents List/SSN Information/Mailing Information... 1 page 2. 686-027... Application Instructions Checklist...2 pages

More information

Instructions for Social Worker Licensure Application New applicants and reciprocity applicants

Instructions for Social Worker Licensure Application New applicants and reciprocity applicants The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Social Workers c/o ASWB P.O. Box 1508 Culpeper, VA 22701 (866) 527-2384 Instructions for Social Worker Licensure

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Temporary Physical Therapist Temporary Physical Therapist Assistant APPLICANT INFORMATION Full Legal

More information

LICENSURE BY EXAMINATION APPLICATION

LICENSURE BY EXAMINATION APPLICATION LICENSURE BY EXAMINATION APPLICATION SEND APPLICATION TO: PSI/Colorado Barber Cosmetology Program PO Box 887 Wheat Ridge, CO 80034 EXAMINATION Please select practical skills examination(s) that you are

More information

STATE OF VERMONT BOARD OF DENTAL EXAMINERS APPLICANT S APPLYING FOR LICENSURE AS A DENTAL HYGIENIST INSTRUCTIONS

STATE OF VERMONT BOARD OF DENTAL EXAMINERS APPLICANT S APPLYING FOR LICENSURE AS A DENTAL HYGIENIST INSTRUCTIONS STATE OF VERMONT BOARD OF DENTAL EXAMINERS APPLICANT S APPLYING FOR LICENSURE AS A DENTAL HYGIENIST INSTRUCTIONS Completed Application (All Applicant s) Fee of $150.00 made payable to the Vermont Secretary

More information

Dear Applicant: Sincerely, Kelli Dalrymple, Coordinator Medical and Specialized Health. Licensure Unit

Dear Applicant: Sincerely, Kelli Dalrymple, Coordinator Medical and Specialized Health. Licensure Unit Please Reply To: Licensure Unit P.O. Box 94986, Lincoln, NE 68509-4986 Phone (402) 471-2118 FAX (402) 471-3577 Dear Applicant: Thank you for your interest in becoming licensed to practice your profession

More information

APPLICATION FOR LICENSURE/LIMITED PERMIT

APPLICATION FOR LICENSURE/LIMITED PERMIT WEST VIRGINIA BOARD OF OCCUPATIONAL THERAPY 1063 Maple Dr., Suite 4B Morgantown, WV 26505 304-285-3150 www.wvbot.org APPLICATION FOR LICENSURE/LIMITED PERMIT BOARD USE ONLY Mailed to/date: Date application/fee

More information

State of Tennessee Department of Health BOARD OF VETERINARY MEDICAL EXAMINERS

State of Tennessee Department of Health BOARD OF VETERINARY MEDICAL EXAMINERS State of Tennessee Department of Health BOARD OF VETERINARY MEDICAL EXAMINERS 665 Mainstream Drive Nashville TN 37243 (Toll Free Instate) 1-800-778-4123 Ext. 5325090 615-532-5090 tn.gov/health Procedures

More information

APPLICATION FOR RESTRICTED DENTAL LICENSE NON-REFUNDABLE APPLICATION FEE $200 WELL-BEING PROGRAM FEE $25

APPLICATION FOR RESTRICTED DENTAL LICENSE NON-REFUNDABLE APPLICATION FEE $200 WELL-BEING PROGRAM FEE $25 Louisiana State Board of Dentistry 365 Canal Street ~ Suite 2680 New Orleans, Louisiana 70130 504.568.8574 Telephone ~ 504.568.8598 Fax www.lsbd.org APPLICATION FOR RESTRICTED DENTAL LICENSE NON-REFUNDABLE

More information

APPLICATION FOR LICENSURE AS AN INSTALLMENT SELLER

APPLICATION FOR LICENSURE AS AN INSTALLMENT SELLER APPLICATION FOR LICENSURE AS AN INSTALLMENT SELLER PART 1 The Pennsylvania Department of Banking and Securities (the Department) welcomes your request for this Installment Seller application. It is the

More information

VOCATIONAL REHABILITATION COUNSELOR

VOCATIONAL REHABILITATION COUNSELOR STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE VOCATIONAL REHABILITATION COUNSELOR APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division

More information

VETERINARY MEDICINE LICENSE APPLICATION INSTRUCTIONS AND INFORMATION

VETERINARY MEDICINE LICENSE APPLICATION INSTRUCTIONS AND INFORMATION The Commonwealth of Massachusetts Division of Professional Licensure Board of Registration of Veterinary Medicine 1000 Washington Street, Suite 710 Boston, MA 02118-6100 Phone: (617) 727-3080 VETERINARY

More information

ALL CANDIDATES MUST TAKE A PRACTICAL & WRITTEN EXAM

ALL CANDIDATES MUST TAKE A PRACTICAL & WRITTEN EXAM 617-727-9940 Effective May 12, 2009 OUT OF STATE APPLICANTS INSTRUCTION SHEET ALL CANDIDATES MUST TAKE A PRACTICAL & WRITTEN EXAM A COMPLETED APPLICATION MUST INCLUDE: A small 2 x 2 photo Money Oorder

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY DENTAL RADIOGRAPHY CERTIFICATION APPLICATION Chapter 466.004 and 466.017(5), Florida Statutes Rule 64B5-9.011, Florida Administrative Code SPECIAL TES AND INSTRUCTIONS: 1. A N-REFUNDABLE fee of $35.00

More information

INSTRUCTIONS: FULL-REPORTING CPA LICENSE APPLICATION

INSTRUCTIONS: FULL-REPORTING CPA LICENSE APPLICATION COMMONWEALTH OF MASSACHUSETTS Board of Public Accountancy 1000 Washington Street, Suite 710 Boston, MA 02118-6100 617-727-1806 www.mass.gov/dpl/boards/pa INSTRUCTIONS: FULL-REPORTING CPA LICENSE APPLICATION

More information

APPLICANT INFORMATION FOR LICENSURE AS A MARRIAGE & FAMILY THERAPIST

APPLICANT INFORMATION FOR LICENSURE AS A MARRIAGE & FAMILY THERAPIST The Commonwealth of Massachusetts Division of Professional Licensure Board of Allied Mental Health and Human Services Professions 1000 Washington Street, Suite 710 Boston, MA 02118-6100 APPLICANT INFORMATION

More information

APPLICATION FOR GEOLOGIST LICENSURE BY RECIPROCITY INSTRUCTION SHEET

APPLICATION FOR GEOLOGIST LICENSURE BY RECIPROCITY INSTRUCTION SHEET CANNON BUILDING STATE OF DELAWARE TELEPHONE: (302) 744-4500 861 SILVER LAKE BLVD., SUITE 203 DEPARTMENT OF STATE FAX: (302) 739-2711 DOVER, DELAWARE 19904-2467 DIVISION OF PROFESSIONAL REGULATION WEBSITE:

More information

PHARMACIST LICENSE APPLICATION

PHARMACIST LICENSE APPLICATION THE STATE Department Commerce, Community, and Economic Development In accordance with AS 08.80.410, a person may not assume or use the title "pharmacist," or any variation the title, or hold out to be

More information

MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.maryland.

MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.maryland. MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS 4201 PATTERSON AVENUE 316 BALTIMORE, MARYLAND 21215 410-764-4732 www.dhmh.maryland.gov/bopc/ INSTRUCTIONS ALCOHOL AND OTHER DRUG COUNSELING OUT

More information

BOARD OF MEDICINE APPLICATION MATERIALS FOR INITIAL REGISTRATION & RENEWAL OF INTERN/RESIDENT/FELLOW & HOUSE PHYSICIAN PURSUANT TO 458.345, F.S.

BOARD OF MEDICINE APPLICATION MATERIALS FOR INITIAL REGISTRATION & RENEWAL OF INTERN/RESIDENT/FELLOW & HOUSE PHYSICIAN PURSUANT TO 458.345, F.S. BOARD OF MEDICINE APPLICATION MATERIALS FOR INITIAL REGISTRATION & RENEWAL OF INTERN/RESIDENT/FELLOW & HOUSE PHYSICIAN PURSUANT TO 458.345, F.S. DEPARTMENT OF HEALTH 1 TABLE OF CONTENTS SECTION I: Application

More information