Free 50791.FH11 - Indiana


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State: Indiana
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AFFIDAVIT OF SUPERVISION STUDENT HEARING AID DEALER CERTIFICATE
State Form 50791 (R2 / 7-07)

INSTRUCTIONS:

1. Affidavit to be completed by REGISTERED SUPERVISING HEARING AID DEALER of the students training period. 2. Give estimates of number of hours of supervised training. 3. Return form to: Professional Licensing Agency Committee of Hearing Aid Dealer Examiners 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2064

State in which affidavit executed

County in which affidavit executed

Date affidavit executed (month, day, year)

REGISTERED HEARING AID DEALER
Name of registered hearing aid dealer (first, middle, last) Name of company / facility Address of company / facility (number and street, city, state, and ZIP code) Hearing aid dealer registration number E-mail address

STUDENT HEARING AID DEALER INFORMATION
Name of student (first, middle, last) Address of student (number and street, city, state, and ZIP code) Students hearing aid dealer certificate number

WEEK(s) SUPERVISED DATE Month Year

NUMBER OF HOURS SUPERVISED EACH MONTH

WEEK(s) SUPERVISED DATE Month Year

NUMBER OF HOURS SUPERVISED EACH MONTH

TOTAL number of weeks supervised

TOTAL number of hours supervised

The above supervision information was taken from payroll or other records which are kept at (company / facility name):

AFFIDAVIT

On this day, I certify that I am a registered Hearing Aid Dealer holding the registration number listed above, and that the above name Student Hearing Aid Dealer, located at the address indicated, was under my supervision for the total number of hours, and for the length of time listed above for the above named company / facility. I solemnly swear, or affirm that the statements given above are true and correct to the best of my knowledge.
Signature of registered Hearing Aid Dealer Date signed (month, day, year)