Free 53327.FH11 - Indiana

APPLICATION FOR REPEAT EXAMINATION FOR PSYCHOLOGY
State Form 53327 (8-07) Approved by State Board of Accounts, 2007

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

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Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

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

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

DO NOT WRITE ABOVE THIS LINE
Please check one: Law Examination for Professional Practice in Psychology (EPPP)

EPPP is given by computer. Information regarding testing will be sent after passing of the jurisprudence examination.
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Telephone number (daytime) State E-mail address Number of times previously taken Social Security number * Date of birth (month, day, year) ZIP code

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Name of school

If your answer is Yes to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including the location, date and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of the license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied licensure, registration, certification, or permit to practice psychology or any regulated health occupation in any state (including Indiana) or country? (Note: if only denial is because you failed this licensing exam, do not mark Yes) 3. Are you now being or have you ever been treated for drug or alcohol abuse? 4. 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. To any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been admonished, censored, 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? If this information has been submitted with your original application and has not changed please check here: You only need to submit additional information if circumstances have changed since you last submitted an explanation regarding these questions. 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 (month, day, year)

Yes

No

Yes Yes

No No

Yes Yes Yes

No No No