Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application

Size: px
Start display at page:

Download "Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application"

Transcription

1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Occupation Therapy Advisors Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application Current Expiration 05/31/2016 Renewal Period Covering 06/01/2016 through 05/31/2018 Renewal Application Fee $ n Refundable Processing Fee Checks Payable to: Vermont Secretary of State You Must Complete The Information Below: For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal fee is non-refundable. If the completed renewal application, along with all supporting documentation, is not received in the Office by the expiration date, you will be required to pay an additional penalty in addition to the renewal fee. Call the Office for a calculation of the penalty before submitting this renewal application. Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country Street/Apt # If your 911 address has changed, indicate your new address in the box to the right. Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female

2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license. Name (print): License Number: 2

3 Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3

4 Section D: Continuing Education Requirement You are not required to send any supporting documentation with this form if you renew by the license expiration date. The Office of Professional Regulation reserves the right to verify information submitted by applicants for renewal and conducts a random audit of CE for each profession. You must retain all documentation for seven years after completion of the program/course. Please complete the Continuing Education Record on the next page. If you are renewing more than 30 days late, you must submit all CE documents with your completed renewal form. Occupational Therapists and Occupational Therapy Assistants Administrative Rule 3.2 (a) Continuing Competence Requirements (a) "Continuing competence" means the direct involvement of an occupational therapist or occupational therapy assistant as a participant in activities promoting continuing competency in occupational therapy theory and practice. A total of 20 hours of continuing competence shall be earned in a two year renewal period. An occupational therapist or occupational therapy assistant who is renewing his or her license for the first time after initial licensure is subject to a 10 hour continuing competence requirement per full year of licensure. If the license has been held for one year or less, no continuing competence is required. If held more than one year but less than two years, ten hours is required. Continuing Education Requirement (Check the box that applies to your license.) Current NBCOT (National Board for Certification in Occupational Therapy) Certification. My Occupational Therapist/Occupational Therapy Assistant s license was first issued in Vermont prior to 06/01/2014 AND I have completed 20 hours of continuing education. (I do not hold a current NBCOT certification) My Occupational Therapist/Occupational Therapy Assistant s license was first issued in Vermont between 06/01/2014 and 05/31/2015 AND I have completed 10 hours of continuing education. My Occupational Therapist/Occupational Therapy Assistant s license was first issued in Vermont on or after 06/01/2015; therefore I do not have to complete continuing education for this renewal cycle (0 hours). I have NOT met the continuing education requirement (CE extensions may be granted in exceptional circumstances for good cause shown upon written request with a completed renewal form and fee submitted prior to the expiration date.) Name (print): License Number: 4

5 Itemize the education courses taken over the past two years (submit additional sheets if more space is needed) TITLE & CONTENT OF PROGRAM SPONSORING ORGANIZATION # OF CREDITS/HOURS AWARDED DATES TOTAL # OF CREDITS/HOURS: Name (print): License Number: 5

6 Section E: Expired Renewal If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section F: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Signature Date (MM/DD/YYYY) Print Name: License # ---- Name (print): License Number: 6

7 Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2016 Renewal License #: Name: Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 7

8 47832 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPIST ASSISTANT 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 1 Vermont License Number First Name - (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) Middle Name Last Name 1. Gender: Male Female 2. Are you Hispanic or Latino/a? Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Choose not to respond Birthdate (mm-dd-yyyy) Race? (check all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or Pacific Islander White Other Choose not to respond 4. What is your highest OT-related degree? Associate Degree (AA, etc) Bachelor s Degree (BS, BA, etc) Master's Degree (MS, MA, etc) Specialist Degree / Certificate Doctorate (PhD, etc) Other (please specify) 5. In what year did you complete your highest related degree? 6. Enter the two-letter code for the state where you completed your highest related degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. Are you certified by any certification board? yes, by the NBCOT yes, by the Society of hand therapists yes, by some other board no 8. Are you certified in a subspecialty by the American Occupational Therapy Association (AOTA)? yes, in neurology yes, in pediatrics yes, in gerontology Other (please specify) 9. In what year did you obtain your first OT license? Please continue on next page. Thank you

9 47832 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPIST ASSISTANT 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 2 Vermont License Number (Please re-enter your license number for scanning purposes) 10. Are you actively working in Vermont as an OTA? 11. IF you are not actively working in Vermont as an OTA, Do you plan to start (or resume) work and/or clinical practice in Vermont within the next 12 months? 12. IF you are not actively working in Vermont as an OTA, Please describe your current employment status: (check all that apply) Actively working OUTSIDE Vermont in a position that requires your OTA license Actively working in an OTA position that does not require an OTA license Actively working in a different field t currently working Retired * IF you are NOT actively working IN VERMONT as an OTA, PLEASE STOP HERE AND RETURN SURVEY 13. Which of the following best describes your current employment arrangement at your primary Vermont practice location regarding direct client / patient care? Self employed Salaried employment Contract employment Hourly employment Temporary Employment Other 14. What are your employment plans for the next 12 months? Continue as you are Increase hours Decrease hours Stop working in VT as an Occupational Therapist Assistant Unsure Please continue on next page. Thank you

10 47832 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPIST ASSISTANT 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 3 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. SITE ONE (principal site) - town for the Vermont location where you work, not a mailing address: Practice Name and Street address (not a mailing address): ZIP code: This site is a (please choose ONE): Hospital/Medical Center Acute care setting Private Practice Skilled Nursing Facility Health Clinic/Outpatient Facility Rehabilitation Unit Assisted Living Nursing Home School or College Mental Health Program Home Health Patients work site Business or industrial workplace Community / Social service agency Other: During how many weeks in a year do you work at this site as an OTA: (48 weeks is considered "year round") - Weeks Per Year What is your primary specialty area of practice at this site? (select ONE) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the primary specialty mentioned above: Hours per week Please continue on next page. Thank you

11 47832 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPIST ASSISTANT 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 4 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Administration / Management Teaching/Education/Research Other activities Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the secondary specialty mentioned above (if any): Hours per week * If you have a second practice site, continue on the next page. If you only have one practice site, stop here, but please return all 6 pages. Please return all sheets (6 pages) even if some are blank. Thank you

12 47832 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPIST ASSISTANT 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 5 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. SITE TWO (if any) - town for the Vermont location where you work, not a mailing address: Practice Name and Street address (not a mailing address): ZIP code: This site is a (please choose ONE): Hospital/Medical Center Acute care setting Private Practice Skilled Nursing Facility Health Clinic/Outpatient Facility Rehabilitation Unit Assisted Living Nursing Home School or College Mental Health Program Home Health Patients work site Business or industrial workplace Community / Social service agency Other: During how many weeks in a year do you work at this site as an OTA: (48 weeks is considered "year round") - Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the primary specialty mentioned above: Hours per week Please continue on next page. Thank you

13 47832 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPIST ASSISTANT 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 6 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Administration / Management Teaching/Education/Research Other activities Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the secondary specialty mentioned above (if any): Hours per week If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, specialty, weeks and hours: more Please return all sheets (6 pages) even if some are blank. Thank you

Licensed Independent Clinical Social Workers Renewal/Reinstatement Application

Licensed Independent Clinical Social Workers Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Clinical Social Workers 802-828-1505 renewalclerk@sec.state.vt.us www.vtprofessionals.org

More information

Pharmacy Technician Renewal/Reinstatement Application

Pharmacy Technician Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St 3 rd Floor Montpelier, VT 05620-3402 Pharmacy Technician Renewal/Reinstatement Application Board of Pharmacy

More information

Licensed Clinical Mental Health Counselor Renewal Application

Licensed Clinical Mental Health Counselor Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Licensed Clinical Mental Health Counselor Renewal Application Board of

More information

Traditional Dental Assistant Renewal Application

Traditional Dental Assistant Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 056203402 Traditional Dental Assistant Renewal Application Board of Dental Examiners

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

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

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

Registered Nurse Renewal/Reinstatement Application

Registered Nurse 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 Nursing Renewal Clerk (802) 828-2396 www.vtprofessionals.org Current

More information

Pharmacy Intern Renewal Application

Pharmacy Intern Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Pharmacy Intern Renewal Application Board of Pharmacy Renewal Clerk (802)

More information

Dental Hygienist Renewal Application

Dental Hygienist Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3420 Dental Hygienist Renewal Application Board of Dental Examiners Renewal

More information

Advanced Practice Registered Nurse Renewal/Reinstatement Application Current Expiration 03/31/2015

Advanced Practice Registered Nurse Renewal/Reinstatement Application Current Expiration 03/31/2015 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 056203402 Board of Nursing (802) 8285924 www.vtprofessionals.org Advanced Practice

More information

Radiologic Technologist Renewal/Reinstatement Application

Radiologic Technologist Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3420 Board of Radiologic Technology Renewal Clerk (802) 828-1505 www.vtprofessionals.org

More information

Psychology (Doctorate/Masters) Renewal Application

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

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 802-828-1505 renewalclerk@sec.state.vt.us

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

BOARD OF DENTAL EXAMINERS Application for Registration as a Dental Assistant (Traditional/Certified)

BOARD OF DENTAL EXAMINERS Application for Registration as a Dental Assistant (Traditional/Certified) Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Diane Lafaille Licensing Board Specialist (802) 828 2390 diane.lafaille@sec.state.vt.us

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

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

INSTRUCTIONS TO APPLICANTS

INSTRUCTIONS TO APPLICANTS Vermont Secretary of State Office of Professional Regulation Board of Pharmacy 89 Main Street, 3 rd Floor Montpelier, Vermont 05620-3402 Phone: (802) 828-2373 Fax: (802) 828-2465 E-Mail: Aprille.Morrison@sec.state.vt.us

More information

APPLICATION FOR ATHLETIC TRAINER LICENSURE INSTRUCTION TO APPLICANTS

APPLICATION FOR ATHLETIC TRAINER LICENSURE INSTRUCTION TO APPLICANTS Judith Griffen, Administrative Assistant ATHLETIC TRAINER APPLICATION FOR ATHLETIC TRAINER LICENSURE INSTRUCTION TO APPLICANTS A. LICENSE BY EXPERIENCE: Applicants must submit the following: 1. Complete

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED NURSING ASSISTANT

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED NURSING ASSISTANT Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-3089 www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED

More information

ELECTROLOGIST APPLICATION FOR ELECTROLOGIST INSTRUCTION TO APPLICANTS. A. LICENSE BY EXAMINATION: Applicants must submit the following:

ELECTROLOGIST APPLICATION FOR ELECTROLOGIST INSTRUCTION TO APPLICANTS. A. LICENSE BY EXAMINATION: Applicants must submit the following: Vermont Secretary of State Montpelier VT 05620-3402 Kara Shangraw Licensing Board Specialist (802) 828-1134 kara.shangraw@sec.state.vt.us www.vtprofessionals.org ELECTROLOGIST APPLICATION FOR ELECTROLOGIST

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

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

Instructions for Persons Applying to be Licensed as a Real Estate Salesperson or Broker

Instructions for Persons Applying to be Licensed as a Real Estate Salesperson or Broker Instructions for Persons Applying to be Licensed as a Real Estate Salesperson or Broker Your application must be complete or it will be returned. te: Applicant s must have taken and passed both parts of

More information

Applicants for Entry on the Roster of Non-Licensed Non-Certified Psychotherapists

Applicants for Entry on the Roster of Non-Licensed Non-Certified Psychotherapists Applicants for Entry on the Roster of n-licensed n-certified Psychotherapists Steps for Applying: 1. Complete the application. 2. Submit the completed application and the $75 non-refundable application

More information

LP License Expires 90 days from date of NBCOT Eligibility to Test Letter PERSONAL INFORMATION EDUCATION LICENSURE & HISTORY INFORMATION

LP License Expires 90 days from date of NBCOT Eligibility to Test Letter PERSONAL INFORMATION EDUCATION LICENSURE & HISTORY INFORMATION Oregon Occupational Therapy Licensing Board State Office Building, 800 NE Oregon St., Suite 407 Portland, OR 97232 www.otlb.state.or.us Phone: 971-673-0198 FAX: 971-673-0226 Felicia Holgate, Director Felicia.M.Holgate@state.or.us

More information

Applicants for Licensure as a Clinical Mental Health Counselor

Applicants for Licensure as a Clinical Mental Health Counselor Steps for Applying by Examination: Applicants for Licensure as a Clinical Mental Health Counselor 1. Submit the completed application and the $125 non-refundable application fee, payable to the Vermont

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

APPLICATION FOR TEMPORARY VOLUNTEER DENTIST S LICENSE

APPLICATION FOR TEMPORARY VOLUNTEER DENTIST S LICENSE Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8511 APPLICATION FOR TEMPORARY VOLUNTEER DENTIST S LICENSE

More information

2015 RENEWAL INFORMATION & INSTRUCTIONS

2015 RENEWAL INFORMATION & INSTRUCTIONS DHMH MARYLAND BOARD OF SOCIAL WORK EXAMINERS 4201 Patterson Avenue, Baltimore, MD 21215-2299 Phone Numbers: 410-764-4788 or Toll Free 1-877-526-2541 www.dhmh.maryland.gov/bswe/ YOUR LICENSE EXPIRES ON

More information

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. State of Florida Department of Business and Professional Regulation Board of Cosmetology Application for Hair Braiding, Hair Wrapping and Body Wrapping Registration Form # DBPR COSMO 5 1 of 7 APPLICATION

More information

CERTIFIED MEDICAL LANGUAGE INTERPRETER

CERTIFIED MEDICAL LANGUAGE INTERPRETER STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR CERTIFICATION CERTIFIED MEDICAL LANGUAGE INTERPRETER APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah

More information

APPLICATION FOR ADVANCED REGISTERED NURSE PRACTITIONER

APPLICATION FOR ADVANCED REGISTERED NURSE PRACTITIONER IOWA BOARD OF NURSING 400 SW 8 th St., Suite B Des Moines, IA 50309-4685 APPLICATION FOR ADVANCED REGISTERED NURSE PRACTITIONER Privacy Act Notice: Disclosure of your Social Security Number on this license

More information

INSTRUCTIONS FOR EMS EXAMINATION AND LICENSURE/CERTIFICATION APPLICATION

INSTRUCTIONS FOR EMS EXAMINATION AND LICENSURE/CERTIFICATION APPLICATION INSTRUCTIONS FOR EMS EXAMINATION AND LICENSURE/CERTIFICATION APPLICATION ALL COURSEWORK AND FINAL EXAMS MUST BE COMPLETED PRIOR TO APPLICATION. Provide all applicable information requested. Missing information

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

REVISED 07-15 STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649

REVISED 07-15 STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email st-socialwork@pa.gov www.dos.pa.gov/social APPLICATION FOR A LICENSE

More information

APPLICANTS MUST COMPLETE THE FOLLOWING: MEDICAL EDUCATION AND TRAINING

APPLICANTS MUST COMPLETE THE FOLLOWING: MEDICAL EDUCATION AND TRAINING Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR

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

MARYLAND BOARD OF PHYSICIANS. Registration and Re-registration Instructions for Unlicensed Medical Practitioners (UMP)

MARYLAND BOARD OF PHYSICIANS. Registration and Re-registration Instructions for Unlicensed Medical Practitioners (UMP) MARYLAND BOARD OF PHYSICIANS Registration and Re-registration Instructions for Unlicensed Medical Practitioners (UMP) Chief of Service - Responsibility The Maryland Annotated Code, Health Occupations 14-302(1)

More information

DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292

DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292 DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292 PHARMACY TECHNICIAN REGISTRATION APPLICATION AND INSTRUCTIONS October

More information

APPLICANTS MUST COMPLETE THE FOLLOWING:

APPLICANTS MUST COMPLETE THE FOLLOWING: Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR

More information

REQUIREMENTS FOR LICENSURE:

REQUIREMENTS FOR LICENSURE: Email: st-medicine@pa.gov INITIAL APPLICATION FOR A NURSE-MIDWIFE LICENSE 1. This license class does not include prescriptive authority. If you wish to hold a certificate for prescriptive authority, you

More information

INSTRUCTIONS FOR APPLICANTS WHO HOLD NBRC CERTIFICATION

INSTRUCTIONS FOR APPLICANTS WHO HOLD NBRC CERTIFICATION Email: st-medicine@pa.gov st-osteopahtic@pa.gov Medicine 717-783-1400/717-787-2381 Osteopathic 717-783-4858 APPLICATION FOR LICENSURE AS A RESPIRATORY THERAPIST This application can be used for licensure

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

2. Be of good moral character. Have 2 recommendations completed on page 3.

2. Be of good moral character. Have 2 recommendations completed on page 3. STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1389 FAX 717-787-7769 Email st-socialwork@state.pa.us Website www.dos.pa.gov/social

More information

APPLICATION FOR A LICENSE TO PRACTICE SOCIAL WORK (THIS APPLICATION MUST BE SUBMITTED FOR PRE-APPROVAL TO TAKE THE ASWB MASTER S EXAMINATION)

APPLICATION FOR A LICENSE TO PRACTICE SOCIAL WORK (THIS APPLICATION MUST BE SUBMITTED FOR PRE-APPROVAL TO TAKE THE ASWB MASTER S EXAMINATION) STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P O BOX 2649 HARRISBURG, PA 17105 717-783-1389 st-socialwork@pa.gov Fax 717-787-7769 www.dos.pa.gov/social APPLICATION

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

STATE OF MAINE OCCUPATIONAL THERAPY PRACTICE APPLICATION FOR LICENSURE

STATE OF MAINE OCCUPATIONAL THERAPY PRACTICE APPLICATION FOR LICENSURE STATE OF MAINE OCCUPATIONAL THERAPY PRACTICE APPLICATION FOR LICENSURE Temporary Occupational Therapist Temporary Occupational Therapy Assistant Department of Professional and Financial Regulation Office

More information

KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929

KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 INSTRUCTIONS FOR COMPLETION OF RENEWAL APPLICATION Online Renewal is available!!!

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Occupational Therapists For the Massachusetts Board of Allied Health Professionals

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

APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form)

APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form) APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form) PDE USE ONLY CONTROL NO. APPLICANTS: Please note the following information

More information

3. Home Phone: (Include Area Code) Cell Phone: 7. Daytime/Business Phone: (Include Area Code)

3. Home Phone: (Include Area Code) Cell Phone: 7. Daytime/Business Phone: (Include Area Code) APPLICATION FOR EMPLOYMENT ST. MARY S COUNTY HUMAN RESOURCES P. O. BOX 653, LEONARDTOWN, MARYLAND 20650 301-475-4200, ext. 1100 Fax 301-475-4082 St. Mary s County Government is an equal opportunity employer

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

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

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

Instructions For Clinical Nurse Specialist (CNS) Applicants

Instructions For Clinical Nurse Specialist (CNS) Applicants RETAIN FOR REFERENCE Instructions For Clinical Nurse Specialist (CNS) Applicants GENERAL INFORMATION: An applicant for Clinical Nurse Specialist certification must hold a current, unrestricted license

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

RADIOLOGIC TECHNOLOGIST or RADIOLOGY PRACTICAL TECHNICIAN

RADIOLOGIC TECHNOLOGIST or RADIOLOGY PRACTICAL TECHNICIAN STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE RADIOLOGIC TECHNOLOGIST or RADIOLOGY PRACTICAL TECHNICIAN APPLICATION INSTRUCTIONS AND INFORMATION General Statement:

More information

INFORMATION/INSTRUCTION SHEET CERTIFIED PODIATRIC X-RAY ASSISTANT

INFORMATION/INSTRUCTION SHEET CERTIFIED PODIATRIC X-RAY ASSISTANT Chapter 461, Florida Statutes Rule Chapter 64B18-24, Florida Administrative Code INFORMATION/INSTRUCTION SHEET CERTIFIED PODIATRIC X-RAY ASSISTANT Any Certified Podiatric X-ray Assistant may perform services

More information

PLEASE READ. (g) Trainees must notify the Board in writing of any changes in employment and change in address of residence.

PLEASE READ. (g) Trainees must notify the Board in writing of any changes in employment and change in address of residence. PLEASE READ WHAT YOU NEED TO DO PRIOR TO SENDING YOUR APPLICATION: Before you submit any documentation make copies of all your documents. All materials, once received, become the property of the Board

More information

CHECK THE CIRCUMSTANCE UNDER WHICH YOU ARE SEEKING A TEMPORARY LICENSE: REQUIRED DOCUMENTS

CHECK THE CIRCUMSTANCE UNDER WHICH YOU ARE SEEKING A TEMPORARY LICENSE: REQUIRED DOCUMENTS Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 717-783-1400/717-787-2381 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 APPLICATION FOR

More information

October 20, 2010. Sincerely, Erin Grupp, MSW, LCAS DWI Services Specialist

October 20, 2010. Sincerely, Erin Grupp, MSW, LCAS DWI Services Specialist North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services 3008 Mail Service Center Raleigh, North Carolina 27699-3008 Tel

More information

Arizona State Board of Nursing (AZBN) School Nurse Initial & Renewal Certification Instructions

Arizona State Board of Nursing (AZBN) School Nurse Initial & Renewal Certification Instructions IMPTANT Arizona State Board of Nursing (AZBN) School Nurse Initial & Renewal Certification Instructions School Nurse Certification is Valid in Arizona only. School Nurse Certification expires every 6 years.

More information

Clinical Nurse Specialist General Instructions for Licensure Application

Clinical Nurse Specialist General Instructions for Licensure Application 4305 S. LOUISE AVENUE SUITE 201 SIOUX FALLS, SD 57106-3115 (605) 362-2760 Fax: 362-2768 doh.sd.gov/boards/nursing General Instructions for Licensure Application Please follow instructions carefully to

More information

Application for Initial Certification Emergency Medical Technician

Application for Initial Certification Emergency Medical Technician Application for Initial Certification Emergency Medical Technician Department Of Health & Social Services Division of Public Health Section of Emergency Programs P.O. Box 110616, Juneau, AK 99811-0616

More information

Boones Creek Animal Hospital PLEASE COMPLETE THE FOLLOWING INFORMATION:

Boones Creek Animal Hospital PLEASE COMPLETE THE FOLLOWING INFORMATION: Boones Creek Animal Hospital PLEASE COMPLETE THE FOLLOWING INFORMATION: Job Applied For: q Receptionist q RVT q Assistant q Other HOW DID YOU LEARN ABOUT THIS POSITION? q Newspaper (List Publication) q

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

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

Nursing Assistant Certified/Endorsement Application Packet

Nursing Assistant Certified/Endorsement Application Packet Nursing Assistant Certified/Endorsement Application Packet Contents: 1. 667-029...Contents List/SSN Information/Mailing Information...1 page 2. 667-030...Application Instructions Checklist...3 pages 3.

More information

INSTRUCTIONS AND APPLICATION: SPECIAL VOLUNTEER LICENSE

INSTRUCTIONS AND APPLICATION: SPECIAL VOLUNTEER LICENSE Oklahoma Board of Nursing 2915 N. Classen Boulevard, Suite #524 Oklahoma City, Oklahoma 73106 (405) 962-1800 www.ok.gov/nursing INSTRUCTIONS AND APPLICATION: SPECIAL VOLUNTEER LICENSE GENERAL INFORMATION

More information

ALL APPLICANTS MUST COMPLETE THE FOLLOWING:

ALL APPLICANTS MUST COMPLETE THE FOLLOWING: APPLICATION FOR ATHLETIC TRAINER LICENSE (This application may also be used for a temporary license) 1. An applicant for licensure shall meet one of the following requirements: a. Be a graduate of an approved

More information

Renewal Application Instructions & Requirements

Renewal Application Instructions & Requirements Certification Office 800 Governors Drive Pierre, South Dakota 57501 certification@state.sd.us Telephone: 605.773.3426 Renewal Application Instructions & Requirements Five-year renewal All credits must

More information

Certified Registered Nurse Anesthetist General Instructions for Licensure Application

Certified Registered Nurse Anesthetist General Instructions for Licensure Application 4305 S. LOUISE AVENUE SUITE 201 SIOUX FALLS, SD 57106-3115 (605) 362-2760 Fax: 362-2768 doh.sd.gov/boards/nursing General Instructions for Licensure Application Please follow instructions carefully to

More information

NEW/RENEWAL APPLICATION FOR PAIN MANAGEMENT CLINIC REGISTRATION

NEW/RENEWAL APPLICATION FOR PAIN MANAGEMENT CLINIC REGISTRATION Department of Regulatory and Economic Resources Business Affairs Division Office of Consumer Protection 601 NW 1st Court, 18th Floor Miami, Florida 33136 Tel: 786-469-2300 Fax: 786-469-2311 email: license@miamidade.gov

More information

PHYSICAL THERAPIST ASSISTANT LICENSURE by ENDORSEMENT

PHYSICAL THERAPIST ASSISTANT LICENSURE by ENDORSEMENT STATE BOARD OF PHYSICAL THERAPY P. O. BOX 2649 717-783-7134 www.dos.pa.gov/physther Application for PHYSICAL THERAPIST or PHYSICAL THERAPIST ASSISTANT LICENSURE by ENDORSEMENT REQUIREMENTS - 1. Graduation

More information

Nursing Assistant Registered Application Packet

Nursing Assistant Registered Application Packet Nursing Assistant Registered Application Packet Contents: 1. 667-025... Contents List/SSN Information/Mailing Information...1 page 2. 667-029... Application Instructions Checklist...2 pages 3. 667-001...

More information

DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE, VIRGINIA 24540 434-799-0456

DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE, VIRGINIA 24540 434-799-0456 APPLICATION FOR EMPLOYMENT DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE, VIRGINIA 24540 434-799-0456 INSTRUCTIONS: PLEASE READ CAREFULLY BEFORE COMPLETING THIS APPLICATION 1. The

More information

California Northstate University College of Pharmacy Transfer Student Application

California Northstate University College of Pharmacy Transfer Student Application California Northstate University College of Pharmacy Transfer Student Application California Northstate University College of Pharmacy Transfer Student Application This admission application packet is

More information

Wisconsin Department of Safety and Professional Services

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: web@dsps.wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov BOARD OF NURSING

More information

UNDERGRADUATE NON-DEGREE ENROLLMENT FORM

UNDERGRADUATE NON-DEGREE ENROLLMENT FORM UNDERGRADUATE NON-DEGREE ENROLLMENT FORM UNDERGRADUATE STUDENTS ONLY: You WILL NOT be eligible for non-degree enrollment if any of the following statements apply to you. If you have: n Previously attended

More information

MONTANA BOARD OF PUBLIC ACCOUNTANTS

MONTANA BOARD OF PUBLIC ACCOUNTANTS MONTANA BOARD OF PUBLIC ACCOUNTANTS 301 South Park 4 th Floor PO Box 200513 Helena Mt 59620 0513 Phone: 406 841 2203 E mail: dlibsdpac@mt.gov Website: www.publicaccountant.mt.gov APPLICATION FOR ORIGINAL

More information

PLEASE ALLOW AT LEAST 60 DAYS FOR PROCESSING INSTRUCTIONS FOR APPLICANTS WHO HOLD NCCPA CERTIFICATION

PLEASE ALLOW AT LEAST 60 DAYS FOR PROCESSING INSTRUCTIONS FOR APPLICANTS WHO HOLD NCCPA CERTIFICATION Regular Mailing Address P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email: st-medicine@pa.gov Courier Delivery Address 2601 NORTH THIRD STREET HARRISBURG, PA 17110 717-783-1400/717-787-2381 APPLICATION FOR

More information

APPLICATION FOR REINSTATEMENT OF NURSE AIDE CERTIFICATION

APPLICATION FOR REINSTATEMENT OF NURSE AIDE CERTIFICATION THE STATE of ALASKA Department of Commerce, Community, and Economic Development Nurse Aide Registry 550 West 7 th Avenue, Suite 1500 Anchorage, AK 99501 Phone: (907) 269-8169 Fax: (907) 269-8196 Email:

More information

Application for Employment

Application for Employment HH AA MM II I L T OO NN HH EE AA L T HH CC EE NN T EE RR,,, II I NN CC... 1 1 0 S 17 T H S T R E E T, H A R R I S B U R G, PA 17104 Application for Employment An Equal Opportunity Employer Hamilton Health

More information

1. Date of Birth (MM) (DD) (YYYY) Place of Birth:

1. Date of Birth (MM) (DD) (YYYY) Place of Birth: For Office Use Only KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 REINSTATEMENT APPLICATION Last Name First Name Middle Name Previous Name (s)

More information

New Jersey Office of the Attorney General. Licensure Application CHECK LIST

New Jersey Office of the Attorney General. Licensure Application CHECK LIST New Jersey Office of the Attorney General Division of Consumer Affairs New Jersey 124 Halsey Street, 6 th Floor, Newark NJ 07102 Licensure Application CHECK LIST PLEASE NOTE: The Applicant Is Responsible

More information

Licensed Clinical Professional Art Therapist LICENSURE APPLICATION INSTRUCTIONS

Licensed Clinical Professional Art Therapist LICENSURE APPLICATION INSTRUCTIONS MARYLAND BOARD OF PROFESSIONAL COUNSELORS AND THERAPISTS Licensed Clinical Professional Art Therapist LICENSURE APPLICATION INSTRUCTIONS *The Application must be on a form currently in use by the Board.

More information

(please attach resume and letters of reference as available)

(please attach resume and letters of reference as available) 100 University Village Ames, IA 50010 (515)294-9838 Childcare Staff Employment Application PERSONAL Name City State Zip Code email address Home phone number If hired, can you show proof of age? Cell phone

More information

APPLE VALLEY COMMUNICATIONS, INC.

APPLE VALLEY COMMUNICATIONS, INC. APPLE VALLEY COMMUNICATIONS Employment Application APPLICANT INFORMATION Last Name First M.I. D.O.B Street Apartment/Unit # City State ZIP Date Available Position Applied for Date you can Start? Social

More information

PLEASE NOTE: If a pending application is older than one year from the date submitted and the applicant wishes to

PLEASE NOTE: If a pending application is older than one year from the date submitted and the applicant wishes to Rev 07/15 STATE BOARD OF EXAMINERS IN SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY P O BOX 2649 HARRISBURG, PA 17105 717-783-1389 www.dos.pa.gov/speech st-speech@pa.gov Application instructions for Licensure

More information

INSTRUCTION SHEET PHARMACY TECHNICIAN

INSTRUCTION SHEET PHARMACY TECHNICIAN INSTRUCTION SHEET PHARMACY TECHNICIAN An applicant for registration as a pharmacy technician may assist a registered pharmacist in the practice of pharmacy for a period of up to 60 days prior to the issuance

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

UNIVERSITY OF ROCHESTER SCHOOL OF NURSING Nurse Practitioner Masters Program Web Page Address: www.son.rochester.edu

UNIVERSITY OF ROCHESTER SCHOOL OF NURSING Nurse Practitioner Masters Program Web Page Address: www.son.rochester.edu UNIVERSITY OF ROCHESTER SCHOOL OF NURSING Nurse Practitioner Masters Program Web Page Address: www.son.rochester.edu Thank you for your interest in the University of Rochester School of Nursing Nurse Practitioner

More information

State of Oregon - Board of Licensed Social Workers 3218 Pringle Rd. SE, Ste. 240, Salem, OR 97302 (503) 378-5735 Oregon.BLSW@state.or.

State of Oregon - Board of Licensed Social Workers 3218 Pringle Rd. SE, Ste. 240, Salem, OR 97302 (503) 378-5735 Oregon.BLSW@state.or. State of Oregon - Board of Licensed Social Workers 3218 Pringle Rd. SE, Ste. 240, Salem, OR 97302 (503) 378-5735 Oregon.BLSW@state.or.us LCSW License Renewal Application License Number: Renewal Date (end

More information

APPLICATION FOR A LICENSE BY EXAMINATION TO PRACTICE MARRIAGE AND FAMILY THERAPY

APPLICATION FOR A LICENSE BY EXAMINATION TO PRACTICE MARRIAGE AND FAMILY THERAPY QUALIFICATIONS STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 Email st-socialwork@state.pa.us Website www.dos.pa.gov/social

More information

PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649

PENNSYLVANIA STATE BOARD OF DENTISTRY P.O. BOX 2649 HARRISBURG, PA 17105-2649 PENNSYLVANIA STATE BOARD OF DENTISTRY APPLICATION FOR CERTIFICATION AS A PUBLIC HEALTH DENTAL HYGIENE PRACTITIONER Introduction: Instructions and Application Form Please read the following instructions

More information

Place of Birth City State Country. Birthdate (mm/dd/yyyy) Permanent address. City State Zip County. ( ) Mailing address if different from above

Place of Birth City State Country. Birthdate (mm/dd/yyyy) Permanent address. City State Zip County.   ( ) Mailing address if different from above Music Therapist License Application Please type or print clearly. It is the responsibility of the applicant to submit all supporting documentation. Failure to do so may result in a delay in processing

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