Licensed Clinical Mental Health Counselor Renewal Application

Size: px
Start display at page:

Download "Licensed Clinical Mental Health Counselor Renewal Application"

Transcription

1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Licensed Clinical Mental Health Counselor Renewal Application Board of Allied Mental Health Renewal Clerk (802) Current Expiration 01/31/2015 You Must Complete The Information Below: Renewal Period Covering 02/01/2015 through 01/31/2017 Renewal Application Fee $ [n Refundable Processing Fee] Checks Payable to: Vermont Secretary of State For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal application fee is non-refundable. If the completed renewal, along with all supporting documentation, is not received in the Office by the expiration date you will be required to pay a late renewal penalty. The penalty is $25.00 for renewals submitted less than 30 days late. Thereafter, the penalty increases by $5.00 for every additional month or fraction of a month, not to exceed $ Reminder: You may not practice your licensed profession without an active license. 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.

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. Board of Allied Mental Health Administrative Rules 3.30 Maintaining a Clinical Mental Health Counselor License, Continuing Education Every licensed clinical mental health counselor must complete 40 continuing education credits in a 24-month renewal period in order to renew the license Continuing Education, Ethics Requirement, Supervision (a) A minimum of four of the 40 hours must be specifically designated as continuing education in professional ethics in the clinical fields of marriage and family therapy, clinical mental health counseling, psychiatry, psychology, or social work. The remaining 36 hours must be in the theory and practice of clinical mental health counseling. (b) Those who serve as supervisors are encouraged to take some continuing education training related to supervision Individualized Learning Activities (b) more than 20 of the 40 hours may be accrued in the category of Individualized Learning Activities. Continuing Education Requirement (Check the box that applies to your license.) My Licensed Clinical Mental Health Counselor license was first issued in Vermont on or after 02/01/2013; therefore I do not have to complete Continuing Education for this renewal cycle (0 hours). My Licensed Clinical Mental Health Counselor license was first issued in Vermont prior to 02/01/2013; and I have completed 40 hours of continuing education, including (4) four hours in professional ethics. 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 **(REQUIRED)** 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) 2015 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 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors 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 Prefer not to answer 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 Prefer not to answer 4. What is your highest counseling degree? Master s degree in counseling or related field Doctoral degree in counseling or related field Other 5. In what year did you complete your initial counseling degree? 6. Enter the two-letter code for the state where you completed your initial counseling degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. Was this a CACREP accredited program when you graduated? Don't know 8. Please check all counseling certifications you currently hold: National Certified Counselor (NCC) Approved Clinical Supervisor (ACS) Other 9. For how many years have you provided direct client care as a licensed Clinical Mental Health Counselor (in any state)? Please continue on next page. Thank you

9 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors 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) 9. Which of the following other licenses, certifications or registrations do you maintain? (Select all that apply) Art therapist Marriage & family therapist Psychoanalyst Psychologist 10. In what state(s) do you hold an active Clinical Mental Health Counselor license? State (postal abbreviation(s)) Social worker Substance abuse/addiction counselor Other 11. Please describe your current employment status: (check all that apply) Actively working in a position that requires a mental health counseling license Actively working in a position that does not require a mental health counseling license Actively working in a field other than mental health counseling t currently working Retired 12. Do you provide direct client care in Vermont as a Clinical Mental Health Counselor? 13. If no, do you plan to start (or resume) direct client care in Vermont as a Clinical Mental Health Counselor within the next 12 months? * IF you are not providing direct patient care IN VERMONT as a Clinical Mental Health Counselor, PLEASE STOP HERE AND RETURN SURVEY 14. For how many years have you provided direct client care in Vermont as a Clinical Mental Health Counselor? 15. What are your plans for the next 12 months regarding direct client care in Vermont? Increase hours in patient care Decrease hours in patient care Seek a non-clinical job Retire Continue as you are Unknown Please continue on next page. Thank you

10 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors 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 client care IN VERMONT. If you provide care at 2 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 Street address (not a mailing address): ZIP code This site is a (please choose ONE): Community Health Center Mental Health Clinic Methadone Clinic Outpatient Medical Care Substance Abuse Treatment Facility Child welfare Criminal Justice Hospital: General Hospital: Psychiatric Private practice: individual Private practice: group Rehabilitation Residential setting School based mental health In-home setting Other: During how many weeks in a year do you work at this site as a Clinical Mental Health Counselor? (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct client care at this site? (select ONE) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you

11 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors 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 client care at this site? (if any) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your secondary specialty area mentioned above: Hours per week Please indicate the average number of hours you spend per working week at this site on additional major activities: Administration / Management 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. Supervision Teaching / Education Research Other activities Please return all sheets (6 pages) even if some are blank. Thank you

12 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors 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 client care IN VERMONT. If you provide care at 2 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 Street address (not a mailing address): ZIP code This site is a (please choose ONE): Community Health Center Mental Health Clinic Methadone Clinic Outpatient Medical Care Substance Abuse Treatment Facility Child welfare Criminal Justice Hospital: General Hospital: Psychiatric Private practice: individual Private practice: group Rehabilitation Residential setting School based mental health In-home setting Other: During how many weeks in a year do you work at this site as a Clinical Mental Health Counselor? (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct client care at this site? (select ONE) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you

13 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors 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 client care at this site? (if any) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your secondary specialty area mentioned above: Hours per week Please indicate the average number of hours you spend per working week at this site on additional major activities: Administration / Management Supervision Teaching / Education Research Other activities 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/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

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

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

Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application

Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Occupation Therapy Advisors 802-828-1505 renewalclerk@sec.state.vt.us 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

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

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

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

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

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

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

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

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

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

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

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

MDS: SUBSTANCE ABUSE/ADDICTION COUNSELORS. Demographics. Education &Training

MDS: SUBSTANCE ABUSE/ADDICTION COUNSELORS. Demographics. Education &Training MDS: SUBSTANCE ABUSE/ADDICTION COUNSELORS Demographics Year 1. Birth date 2. Sex: O Male O Female 3. Race/Ethnicity (mark one or more boxes) O American Indian or Alaska Native O Black or African American

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

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

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: Clinical Mental Health Counselor APPLICANT INFORMATION

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

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

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

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. (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

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

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

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

Social Worker Associate Advanced or Social Worker Associate Independent Clinical License Application Packet

Social Worker Associate Advanced or Social Worker Associate Independent Clinical License Application Packet Social Worker Associate Advanced or Social Worker Associate Independent Clinical License Application Packet Contents: 1. 670-105...Contents List/SSN Information/Mailing Information...1 page 2. 670-106...Application

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

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

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

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

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

Mental Health Counselor Associate. Application Packet. Contents: Important Social Security Number Information: In order to process your request:

Mental Health Counselor Associate. Application Packet. Contents: Important Social Security Number Information: In order to process your request: Mental Health Counselor Associate License Application Packet Contents: 1. 670-100... Contents List/SSN Information/Mailing Information... 1 page 2. 670-101... Application Instructions Checklist...3 pages

More information

Mental Health Counselor Credentialing. Activation Application Packet. Contents: Important Social Security Number Information:

Mental Health Counselor Credentialing. Activation Application Packet. Contents: Important Social Security Number Information: Mental Health Counselor Expired Credential Activation Application Packet Contents: 1. 670-078...Contents List/SSN Information/Mailing Information... 1 page 2. 670-077...Application Instructions Checklist...2

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

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

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

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

APPLICATION FOR LICENSURE LICENSED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR INTERN

APPLICATION FOR LICENSURE LICENSED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR INTERN STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE LICENSED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR CERTIFIED SUBSTANCE ABUSE COUNSELOR INTERN

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

APPLICATION FOR A LICENSE BY EXAMINATION TO PRACTICE PROFESSIONAL COUNSELING QUALIFICATIONS

APPLICATION FOR A LICENSE BY EXAMINATION TO PRACTICE PROFESSIONAL COUNSELING QUALIFICATIONS STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS 717-783-1389 FAX: 717-787-7769 Email st-socialwork@state.pa.us Website www.dos.pa.gov/social APPLICATION FOR A

More information

Department of Health

Department of Health Department of Health Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling MARRIAGE AND FAMILY THERAPY DUAL LICENSURE APPLICATION Qualifications for Marriage and Family

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

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

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

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

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

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

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

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

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

STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS

STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS Board of Massage Therapy 4052 Bald Cypress Way, Bin # C-06 Tallahassee,

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

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

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

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

APPLICATION FOR A BEHAVIOR SPECIALIST LICENSE

APPLICATION FOR A BEHAVIOR SPECIALIST LICENSE Email: st-medicine@pa.gov (01/2016) APPLICATION FOR A BEHAVIOR SPECIALIST LICENSE An application SHOULD NOT be submitted until you have obtained a master s or post master s degree in an approved field

More information

HOUSE BILL No. 2577 page 2

HOUSE BILL No. 2577 page 2 HOUSE BILL No. 2577 AN ACT enacting the addictions counselor licensure act; amending K.S.A. 74-7501 and K.S.A. 2009 Supp. 74-7507 and repealing the existing section; also repealing K.S.A. 65-6601, 65-6602,

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

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

BOARD OF ATHLETIC TRAINING STATE OF FLORIDA EXAMINATION APPLICATION FOR LICENSURE

BOARD OF ATHLETIC TRAINING STATE OF FLORIDA EXAMINATION APPLICATION FOR LICENSURE BOARD OF ATHLETIC TRAINING STATE OF FLORIDA EXAMINATION APPLICATION FOR LICENSURE You must read the laws and rules in order to determine your eligibility for licensure. Chapter 468, Part XIII, Florida

More information

STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHYSICAL THERAPIST

STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHYSICAL THERAPIST STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE PHYSICAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement: The Utah Division of Occupational

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

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 PSYCHOLOGY EXAMINING

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

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: Retired Volunteer Health Care Practitioner APPLICANT

More information

SOCIAL SERVICE WORKER (SSW), CERTIFED SOCIAL WORKER INTERN (CSWI), CERTIFIED SOCIAL WORKER (CSW), or LICENSED CLINICAL SOCIAL WORKER (LCSW)

SOCIAL SERVICE WORKER (SSW), CERTIFED SOCIAL WORKER INTERN (CSWI), CERTIFIED SOCIAL WORKER (CSW), or LICENSED CLINICAL SOCIAL WORKER (LCSW) STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE SOCIAL SERVICE WORKER (SSW), CERTIFED SOCIAL WORKER INTERN (CSWI), CERTIFIED SOCIAL WORKER (CSW), or LICENSED

More information

BOARD OF CHIROPRACTIC MEDICINE GENERAL INFORMATION/INSTRUCTIONS CERTIFIED CHIROPRACTIC PHYSICIANS ASSISTANT

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

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

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

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

Individual Application for Massage Therapy Iowa Department of Public Health/Bureau of Professional Licensure Board Office Telephone (515) 281-6959

Individual Application for Massage Therapy Iowa Department of Public Health/Bureau of Professional Licensure Board Office Telephone (515) 281-6959 For Office Use License #: Date Issued: $120 Individual Application for Massage Therapy Iowa Department of Public Health/Bureau of Professional Licensure Board Office Telephone (515) 281-6959 Applicant

More information

Medical Assistant-Hemodialysis Technician Certification Application Packet

Medical Assistant-Hemodialysis Technician Certification Application Packet Medical Assistant-Hemodialysis Technician Certification Application Packet Contents: 1. 651-011...Contents List/SSN Information/Mailing Information...1 page 2. 651-012...Application Instructions Checklist...2

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

Marriage and Family Therapist Associate

Marriage and Family Therapist Associate Marriage and Family Therapist Associate License Application Packet Contents: 1. 670-096... Contents List/SSN Information/Mailing Information...1 page 2. 670-097... Application Instructions Checklist...3

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

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

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

SOUTHWEST CERTIFICATION BOARD

SOUTHWEST CERTIFICATION BOARD CERTIFICATION APPLICATION Certified Alcohol & Drug Abuse Counselor (CADC I, II) Checklist This form is provided to help you keep track of the necessary steps and forms required for certification PLEASE

More information

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Worker and Supervisor Application

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Worker and Supervisor Application STATE OF CONNECTICUT ASBESTOS Worker and Supervisor Application General Policies and Procedures IMPORTANT: THE DEPARTMENT WILL NOT REVIEW HAND-DELIVERED APPLICATIONS AT THE TIME OF RECEIPT. PROFESSIONAL

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

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

APPLICATION FOR LICENSURE AS A PSYCHOLOGIST

APPLICATION FOR LICENSURE AS A PSYCHOLOGIST APPLICATION FOR LICENSURE AS A PSYCHOLOGIST Application Fee: $40 (Nonrefundable) File #: SECTION I. PErSONAl DATA (Board use only) Last First Middle Initial Jr., Sr., I, II (Note: Formal identification

More information