Free 50328.FH11 - Indiana


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State: Indiana
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APPLICATION FOR APPROVAL TO PROVIDE CATEGORY I CONTINUING EDUCATION FOR PSYCHOLOGISTS
State Form 50328 (R3 / 9-07)

RETURN THIS APPLICATION TO: INDIANA STATE PSYCHOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room 072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

Name of individual or organization Address (number and street, city, state, and ZIP code) Daytime telephone number E-mail address Web address

(

)

Types of continuing education courses to be presented:

Formally Organized Courses

Workshops

Seminars

Symposia

Post Doctoral Institutes

The named individual or organization hereby requests approval to present continuing education programs for psychologists licensed to practice in Indiana and agrees to adhere to all applicable statutes and rules of the Indiana State Psychology Board. I / We will provide verification of attendance to each participating psychologist. SIGNATURE OF AUTHORIZED INDIVIDUAL
Printed name of authorized individual Title Signature of authorized individual 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 information maintained by this agency. The information you provide will become public record.

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, or Indiana State Psychology Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board or any of their authorized representatives in connection with processing this application for approval of an individual or organization to provide continuing education courses. 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 Professional Licensing Agency, or the Indiana State Psychology Board to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, 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 authorized individual Date signed (month, day, year)