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APPLICATION FOR RENEWAL OF A STUDENT HEARING AID DEALER CERTIFICATE
State Form 50688 (R3 / 7-07) Approved by State Board of Accounts, 2007

COMMITTEE OF HEARING AID DEALER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 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
Renewal fee Certificate number Date fee paid (month, day, year) Receipt number C.M.

Date reissued (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) T elephone number Social Security number * Date of birth (month, day, year) E-mail address List other names you have used

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1. What is the certificate number and expiration date of your student hearing aid dealer registration? 2. If your certificate has expired, what have you been doing since the expiration of your permit?

3. If your certificate has expired, have you been dispensing and fitting hearing aids?

4. What is your reason for requesting the renewal of your student hearing aid dealer certificate?

5. Have you taken the hearing aid dealer examination? If Yes, please list the number of times, dates taken and sections passed / failed below.

Yes

No

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6. List all student hearing aid dealer certificate numbers, dates held, and sponsoring hearing aid dealer.

7. Is your sponsoring hearing aid dealer providing direct training? If No, please explain:

Yes

No

8. Have you been directly supervised when you have been fitting and dispensing hearing aids?

9. Describe the supervision by the sponsoring hearing aid dealer. Has the sponsor worked with you, the student hearing aid dealer, concerning the study of literature relating to the practice of hearing aids, testing of the clients, hearing evaluations, impression making and audiogram reviews? (Please list responses below. If additional paper is necessary to respond to the above questions, please attach to the application.)

10. Describe activities with regard to the study of literature including FDA regulations, Indiana statutes, text books, National Hearing Aid Society courses, anatomy and physiologies. (Please list responses below. If additional paper is necessary to respond to the above questions, please attach to the application.)

11. How many audiometric tests have you conducted? 12. How many audiometric test results have been reviewed and with whom? (Please list responses below. If additional paper is necessary to respond to the above questions, please attach to the application.)

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13. How many ear impressions have you made? 14. Describe the practical experience with regards to instrument selection and working with defective instrument repair. (Please list response below. If additional paper is necessary to respond to the above questions, please attach to the application.)

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 hearing and dealer 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

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 student hearing aid dealer Date (month, day, year)

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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 for renewal of certification as a student hearing aid dealer. 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, person, 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 student hearing aid dealer Date (month, day, year)

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TO BE COMPLETED BY THE SPONSORING HEARING AID DEALER
Name of hearing aid dealer sponsor (last, first, middle, maiden) Name of business Business address (number and street or rural route, city, state, and ZIP code) Business telephone number E-mail address Registration number Date of expiration (month, day, year)

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1. Name of student hearing aid dealer and certificate number of whom you are requesting renewal of certification.

2. List all student hearing aid dealers and certificate numbers of who you are sponsoring at this time:

3. Please submit a detailed report outlining the students training and practical experience throughout the previous year. (Please respond below. If additional paper is necessary to respond to the above questions, please attach to the application.)

4. What outline of training do you wish to implement for the coming year? (Please respond below. If additional paper is necessary to respond to the above questions, please attach to the application.)

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 registered hearing aid dealer Date (month, day, year)

(Continued on the reverse side) Page 5 of 7

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 for renewal of certification as a student hearing aid dealer. 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 hearing aid dealer Date (month, day, year)

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TO BE COMPLETED BY THE SPONSORING HEARING AID DEALER AND STUDENT HEARING AID DEALER 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 Sec. 1. (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 the 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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