Free 50320.FH11 - Indiana

APPLICATION FOR REGISTRATION FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY CLINICAL FELLOWSHIP YEAR State Form 50320 (R2 / 2-06) Reset Form Approved by State Board of Accounts, 2006
* 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.

SPEECH LANGUAGE PATHOLOGY AUDIOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2064 E-mail: [email protected]

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER REGISTRATION NUMBER DATE ISSUED (month, day, year) DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY 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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SCHOOL OF GRADUATION NAME OF SCHOOL LOCATION OF SCHOOL DATE OF GRADUATION (month, day, year)

MASTERS DEGREE GRANTED IN:

Speech-Language Pathology Audiology * If your clinical fellowship begins prior to the date of graduation, you must submit a letter from the school which indicates that all requirements have been completed and the date the applicant will graduate.
CLINICAL FELLOWSHIP ANTICIPATED STARTING AND COMPLETION DATE

STARTING DATE (month, day, year)

COMPLETION DATE (month, day, year)

LOCATION OF FELLOWSHIP
Name of hospital or facility Address (number and street or rural route) City Telephone number State E-mail address ZIP code

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LIST ANY ADDITIONAL WORK SITE ADDRESSES ON A SEPARATE SHEET OF PAPER

(Continued on reverse side.)

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. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. 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 that you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice speech-language pathology or audiology 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, pled 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) 6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 8. Have you ever had a malpractice judgment against you or settled any malpractice action? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct. I am aware of the requirements set forth in 880 IAC 1-1-3.1 and understand that I may practice under the direct supervision of the person whose name appears on this application until the expiration of my registration. I hereby certify under penalties of perjury that I have completed all requirements for a masters degree as required by IC 25-35.6 -1-5(2).
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes

No No No No

Yes Yes Yes Yes Yes

No No No No No

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. 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 aurthorization 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)

CLINICAL FELLOW SUPERVISORS INFORMATION
PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS.
SUPERVISORS INFORMATION
Name (last, first, middle, maiden) Indiana license number Address (number and street or rural route) City Telephone number State E-mail address ZIP code Social Security number * Expiration date (month, day, year)

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CLINICAL FELLOW INFORMATION I will be supervising the following clinical fellow, at the dates indicated and at the following location(s):
Name of clinical fellow Starting date (month, day, year) Name of hospital or facility Address (number and street or rural route) City Telephone number State E-mail address ZIP code Social Security number * Completion date (month, day, year)

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LIST ANY ADDITIONAL WORK SITE ADDRESSES ON A SEPARATE SHEET OF PAPER APPLICATION AFFIRMATION I am aware of requirements set forth in 880 IAC 1-1-3.1 and understand and agree that I shall supervise the person for whom this application is submitted.
Signature of supervisor Date signed (month, day, year)

* 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.