Free 43825.FH11 - Indiana

APPLICATION FOR A LICENSE AS A RESPIRATORY CARE PRACTITIONER
State Form 43825 (R4 / 2-06) Approved by State Board of Accounts, 2006

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INSTRUCTIONS:

Please type or print and answer all questions.

RESPIRATORY CARE COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

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

APPLICATION FEE DATE FEE PAID RECEIPT NUMBER LICENSE NUMBER LICENSE ISSUANCE DATE PERMIT NUMBER PERMIT ISSUANCE DATE PERMIT EXPIRATION DATE DO NOT WRITE ABOVE THIS LINE
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) State Place of birth (city and state or country) E-mail address ZIP code Social Security number *

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

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BASIS FOR LICENSURE (Please check one)

EXAMINATION ENDORSEMENT CREDENTIALS

Based upon applying to take the NBRC Examination. Based upon being licensed in another state or coming from a state that does not license or certify but is credentialed by the NBRC. Based upon your NBRC Certification only. (You may not apply based upon credentials if you are licensed or certified in another state or are coming from a state that does not license or certify respiratory care practitioners.) TEMPORARY PERMIT INFORMATION

Do you wish to have a temporary permit issued pending your application for licensure?

Yes

No DATE OF GRADUATION (month, day, year)

GRADUATE OF A SCHOOL OR PROGRAM OF RESPIRATORY CARE NAME OF SCHOOL LOCATION OF SCHOOL

EXAMINATION RECORD EXAMINATION TAKEN National Board for Respiratory Care (NBRC) Other __________________________ Have you ever failed the NBRC examination? Yes No DATE OF MOST RECENT EXAMINATION (month, day, year) WHERE TAKEN HOW MANY TIMES HAVE YOU SAT FOR THIS EXAMINATION

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UNDERGRADUATE AND GRADUATE TRAINING NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED DEGREE GRANTED

STATES LICENSED Do you hold or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation? Yes No If yes, please list all states, including Indiana, in which you have been licensed to practice as a Respiratory Care Practitioner, or any other health related occupation. LICENSE TYPE STATE NUMBER DATE ISSUED EXPIRATION DATE STATUS

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION GENERAL LOCATION

DATES

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION NAME OF EMPLOYER AND ADDRESS RESPONSIBILITIES DATES OF EMPLOYMENT

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 license or permit 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 license, certificate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice respiratory care 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.) 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.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

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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 Professions Licensing Agency and the Respiratory Care Committee 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 a license to practice respiratory care. 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 an effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to the same.
Signature of applicant Date signed (month, day, year)

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VERIFICATION OF LICENSURE RESPIRATORY CARE PRACTITIONER
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: RESPIRATORY CARE COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] APPLICANT INFORMATION
Name (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) State Telephone number (daytime) ZIP code E-mail address Social Security number *

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I hereby authorize the State of ___________________________________, to furnish the Professional Licensing Agency with the information below.
Signature Date signed (month, day, year)

TO BE COMPLETED BY THE STATE BOARD
License number Date of issuance (month, day, year) Expiration date (month, day, year)

License issued based upon: Examination Endorsement National Board of Respiratory Care (NBRC) Credential Other: _____________________________________ Type of examination: NBRC State Constructed Examination (Attach subjects, scores and average) Has this license 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) Date of examination(s) (month, day, year)

Yes

No

PLEASE AFFIX BOARD SEAL

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