Free 50257.FH11 - Indiana

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APPLICATION FOR APPROVAL OF CONTINUING EDUCATION COURSES FOR PSYCHOLOGISTS
State Form 50257 (R2 / 9-07)

RETURN THIS APPLICATION TO: INDIANA STATE PSYCHOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

* Disclosure of your Social Security number is MANDATORY according to IC 4-1-8-1 and this application cannot be processed without it. FOR OFFICE USE ONLY
Date reviewed (month, day, year) Decision: Initials

DO NOT WRITE ABOVE THIS LINE THIS FORM IS TO BE USED BY LICENSED PSYCHOLOGISTS ONLY. IT IS NOT INTENDED FOR USE BY APPLICANTS FOR APPROVAL AS A SPONSOR OF CONTINUING EDUCATION.
Name of applicant License number

Address (number and street, city, state, and ZIP code)

Telephone number (daytime)

E-mail address

Social Security number *

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Title of program attended

Name of sponsor

Name of lecturer

Location of program

Date of program (month, day, year)

Type of program: audio-visual instructional program workshop post doctoral institute other (describe) Number of hours attended Number of credit hours claimed CATEGORY I: CATEGORY II: formally organized course seminar symposia

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 signed (month, day, year)

(Continued on the reverse side)

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize and direct any person, firm, officer, corporation, association, organization, or institution to release to the Professional Licensing Agency, or the Indiana State Psychology Board, any files, documents, records, or other information pertaining to the named applicant requested by the Agency or the Board or any of their authorized representatives, in connection with processing this application for approval of a continuing education course. I hereby release the aforementioned persons, firms, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency or the Indiana State Psychology Board 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 Board, 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 signed (month, day, year)

NOTICE In compliance with IC 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be processed. You have the right to challenge, correct, or explain the information maintained by this agency. The information you provide will become public record. INSTRUCTIONS Complete this form for any continuing education activity that you attend or participate in which has not received prior approval by the board. This form cannot be used for approval of professional supervision. There is a separate form for review of professional supervision. Submit this form with the appropriate documentation including the name of the sponsor, a description of the course as approved by the course sponsor, the date and location of the course, the names of the presenters and their credentials, verification of attendance, and the number of hours for which credit is requested. You must send a copy of the course brochure if one was published. If a brochure was not published, please notify the board of this fact. Do not send the original verification of attendance to the board. You must maintain verification of attendance for five (5) years. If you are audited by the board and do not have verification of attendance, you will not be granted credit for attending the course even if this request form is approved by the board.