Free 43826.FH11 - Indiana

APPLICATION FOR CERTIFICATION AS AN OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT
To Practice in the State of Indiana
State Form 43826 (R7 / 2-06) Approved by the State Board of Accounts, 2006 *Social Security number is required pursuant to I.C. 4-1-8-1. Application fee Date fee paid (month, day, year) Receipt number Certification number Certification issuance date (month, day, year) Temporary permit fee Date fee paid (month, day, year) Receipt number Temporary permit number Temporary permit issuance date (month, day, year)

Reset Form

OCCUPATIONAL THERAPY COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

APPLICANT Attach two (2) passport type quality photographs of yourself taken within the last eight weeks. Please sign each photo at the bottom. Negatives and Polaroids are not acceptable.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name (last, first, middle, maiden) Address (street and number or rural route) City, state, and ZIP code Telephone number (daytime) Date of birth (month, day, year) Place of birth E-mail address Social Security number *

(

)
BASIS FOR CERTIFICATION

Do you desire a temporary permit? Yes
Please check one:

No Occupational Therapist

Examination

Endorsement Occupational Therapy Assistant

If you are applying by examination, what date will you be taking the examination? (Please list date of examination.) Have you previously filed an application for certification as an Occupational Therapist or Occupational Therapy Assistant in the state of Indiana or any other state? (If yes, please give details as to where and when)

Yes Yes

No No

Have you previously taken the certifying examination for an Occupational Therapist or Occupational Therapy Assistant? (If yes, please list date and place) Have you ever failed the certifying examination for an Occupational Therapist or Occupational Therapy Assistant? (If yes, please list date and place.)

Yes

No OCCUPATIONAL THERAPIST / OCCUPATIONAL THERAPY ASSISTANT DEGREE GRANTED BY

Name of school

Location

Date of graduation (month, day, year)

UNDERGRADUATE AND GRADUATE TRAINING NAME OF SCHOOL LOCATION FROM TO (month, year) (month, year) DEGREE

LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE ANY REGULATED HEALTH OCCUPATION. STATE TYPE OF LICENSE/CERTIFICATE NUMBER DATE ISSUED CURRENT STATUS

PLACES OF EMPLOYMENT SINCE GRADUATION NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES

(Begin) DATE (End)

PLACES YOU HAVE LIVED SINCE GRADUATION GENERAL LOCATION

DATE

* If your answer is "yes" to any of the following, explain fully in a sworn affidavit, including all related details. Include the violation, location and date. Falsification of any of the following is grounds for permanent revocation of a certification 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 or certification in any state (including Indiana) or country? 3. Are you now, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pleaded guilty to or nolo contendere to any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. 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? 6. Have you ever been 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? 7. 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.
Signature of applicant Date (month, day, year)

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No

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 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 certification as an occupational therapist or occupational therapy assistant. 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 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.
Date (month, day, year) Signature of applicant