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APPLICATION FOR A STUDENT HEARING AID DEALER CERTIFICATE
State Form 50686 (R3 / 7-07) Approved by State Board of Accounts, 2007

COMMITTEE OF HEARING AID DEALER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room 072 Indianapolis, Indiana 46204 Telephone: (317) 234-2064 E-mail: [email protected]

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

FOR OFFICE USE ONLY
Application fee Certificate number Date fee paid (month, day, year) Receipt number C.M.

Date issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Residence address (number and street or rural route, city, state, and ZIP code) Telephone number Social Security number* List other names you have used E-mail address Date of birth (month, day, year)

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Have you ever held a student hearing aid dealer certificate prior to this application? If yes, you will need to contact the Professional Licensing Agency for an application for renewal of your student hearing aid dealer certificate. Have you ever filed an application, or held any type of certificate in the state of Indiana? If yes, give details.

Yes

No

Yes

No

If you answer yes to any of the following questions, explain fully in a sworn affidavit, including all related details. Include the violation, location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a license, certificate or registration issued pursuant to this application. 1. Have you ever had any disciplinary action taken against any certificate, registration, and / or license held, by a licensing agency or this state, or any other state or jurisdiction? If yes, please list date(s) and details of such action. Yes No

2. Have you ever been convicted of any violation of law relating to drug abuse, controlled substances, narcotic drugs, or any other drugs? If yes, please list date(s) and details of such conviction.

Yes

No

3. Have you ever been convicted of a criminal offense (excluding minor traffic violations) or other offenses as specified in IC 25-1-9? If yes, please list the offense, the court, and the cause number in which you were convicted.

Yes

No

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APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Indiana Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application as a preceptor. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Committee from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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TO BE COMPLETED BY THE REGISTERED HEARING AID DEALER SPONSOR AND STUDENT HEARING AID DEALER
BEFORE A CERTIFICATE OF STUDENT REGISTRATION CAN BE ISSUED, THIS FORM MUST BE COMPLETED AND SIGNED BY THE SPONSORING HEARING AID DEALER AND THE STUDENT HEARING AID DEALER.
Name of registered hearing aid dealer sponsor (last, first, middle, maiden) Name of business Business address (number and street, city, state, and ZIP code) Business telephone number Registration number E-mail address List other names you have used:

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Name of student hearing aid dealer you will be sponsoring:

List all student hearing aid dealers you are sponsoring at this time: NAME SHAD NUMBER EXPIRATION DATE

ACCORDING TO 844 IAC 9-3-2(2) BOTH PARTIES MUST READ AND SIGN THAT THEY UNDERSTAND THE STUDENT / SPONSOR RELATIONSHIP AS SET FORTH IN 844 IAC 9-6-1. 844 IAC 9-6-1 SUPERVISION OF STUDENT HEARING AID DEALERS (a) Supervision means the direct and regular observation and instruction of the student hearing aid dealer by the sponsoring hearing aid dealer and that the sponsor and student shall be present in the same work setting. All tests and fittings performed by the student shall be personally monitored by the sponsor. The student shall meet at least once each working day with the sponsor to review all work performed by the student. This meeting must include the actual presence of the student and sponsor. (b) It shall be the joint responsibility of the student and sponsor to see that all testing and sales documents pertinent to each sale, whether or not the sale was consummated, are submitted to and reviewed by the sponsor for the term of the student certificate. (c) The committee may require a student or sponsor to show proof of the students training and / or the sponsors supervision. (d) A student hearing aid dealer shall clearly identify himself / herself as a student when performing his / her duties. (e) A student shall prominently display his / her certificate of registration as a student hearing aid dealer in the primary location of his / her employment. (f) Any violation of these requirements and standards shall subject the student and sponsor to disciplinary action as provided in IC 25-1-9.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Signature of registered hearing aid dealer Date (month, day, year)

Signature of student hearing aid dealer

Date (month, day, year)

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