Free 46158.FH11 - Indiana

APPLICATION FOR REGISTRATION AS AN ENVIRONMENTAL HEALTH SPECIALIST
State Form 46158 (R3 / 2-06) Approved by State Board of Accounts, 2006

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BOARD OF ENVIRONMENTAL HEALTH SPECIALISTS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2064 E-mail: [email protected]

*Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY
APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER REGISTRATION NUMBER REGISTRATION ISSUE DATE (month, day, year)

APPLICANT Attach two (2) passport-quality photographs of yourself taken not earlier than one (1) year prior to the date of application, dated and signed in the applicants handwriting.

PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS.
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) Place of birth (city and state or country) E-mail address State ZIP code Social Security number *

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APPLYING FOR REGISTRATION BY: (Please check one)

Examination Baccalaureate Degree
NAME OF SCHOOL LOCATION OF SCHOOL

Reciprocity Masters Degree
DATE OF GRADUATION (month, day, year)

PROFESSIONAL EDUCATION DEGREE GRANTED BY:

EXAMINATION RECORD EXAMINATION TAKEN Professional Examination Service (PES) Examination National Environmental Health Association (NEHA) Other Examination _________________________ OTHER PROFESSIONAL EDUCATION NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED (month, day, year) DEGREE GRANTED DATE OF MOST RECENT EXAMINATION (month, day, year) WHERE TAKEN HOW MANY TIMES HAVE YOU SAT FOR THIS EXAMINATION

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VERIFICATION OF PROFESSIONAL EXPERIENCE SUPERVISOR EMPLOYER LOCATION SPECIFIC RESPONSIBILITIES START COMPLETION DATE DATE (month, day, year) (month, day, year)

STATES REGISTERED / LICENSED List all states, including Indiana, in which you have been registered or licensed to practice any regulated health occupation. LICENSE TYPE STATE NUMBER DATE ISSUED (month, day, year) EXPIRATION DATE (month, day, year) STATUS

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION GENERAL LOCATION DATES (month, day, year)

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATES OF EMPLOYMENT (month, day, year)

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a registration issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit for registration as an environmental health specialist or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been treated for drug or alcohol abuse? 5. Have you ever been convicted of, plead guilty, or nolo contendre to: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 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)

YES YES YES YES YES YES

NO NO NO NO NO NO

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AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, corporation, association, organization or institution to release to the 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 for registration as an environmental health specialist. 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. 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)

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VERIFICATION OF ENVIRONMENTAL HEALTH REGISTRATION INSTRUCTIONS: Please complete the top portion of the verification and send a copy to each state where you hold or have held a license. Request each state to complete and send directly to:

Board of Environmental Health Specialists Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2064
APPLICANT INFORMATION
Name (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) State E-mail address ZIP code Social Security number *

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I hereby authorize the State of with the information below.
Signature

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to furnish the Professional Licensing Agency

Date signed (month, day, year)

TO BE COMPLETED BY THE STATE BOARD
License number License issued based upon: Date of issuance (month, day, year) Date of expiration (month, day, year)

Examination
Type of examination:

Endorsement

Other _________________________________
Date of examination(s) (month, day, year)

PES Examination NEHA Examination State Constructed Examination (Attach subjects, scores and average) Has this registration been subject to any disciplinary action? (Please attach certified copies of any disciplinary action taken by your board.) FORM COMPLETED BY:
Name Title State Board Date (month, day, year)

Yes

No

PLEASE AFFIX BOARD SEAL

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VERIFICATION OF PROFESSIONAL EXPERIENCE FOR REGISTERED ENVIRONMENTAL HEALTH SPECIALIST A person applying to be registered as an environmental health specialist must provide verification of two (2) years of professional experience unless the applicant meets the requirements as stated below under one (1) year of experience. TWO (2) YEARS OF EXPERIENCE According to IC 25-32-1-3(b)(2): Must have been employed full time in the field of environmental sanitation for a period of at least two (2) years within the preceding five (5) years. ONE (1) YEAR OF EXPERIENCE According to 896 IAC 1-2-2(7) An applicant who: (A) holds a masters degree in public health with a major in sanitary science or a science degree higher than a baccalaureate; and (B) meets the science requirements set forth in 896 IAC 1-2-2(2) is only required to submit verification of one (1) year of full time employment in the field of environmental health within the proceeding five (5) years. Request your employer(s) to complete this form and return it directly to the: Board of Environmental Health Specialists Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City State ZIP code Social Security number *

SUPERVISOR AND FACILITY / COMPANY EMPLOYED
Name of supervisor Name of facility / company Address (number and street or rural route) City Telephone number (daytime) E-mail address State ZIP code Title

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POSITION AND DATES OF EMPLOYMENT Position Held Starting Date (month, day, year) Ending Date (month, day, year)

RESPONSIBILITIES OF APPLICANT Please list the applicants specific responsibilities when employed by your facility / company. If there is not enough space provided below, please attach information to this form on a separate sheet of paper.

CERTIFICATION OF SUPERVISOR This is to certify that the above applicant has been employed under my supervision in the field of environmental health in the position and dates as stated on this verification of professional experience.
Signature of supervisor Date signed (month, day, year)

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