Free 48168.FH11 - Indiana

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APPLICATION FOR CERTIFICATION TO PRACTICE HYPNOTISM
State Form 48168 (R6 / 7-07) Approved by State Board of Accounts, 2006

INDIANA HYPNOTIST COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3022 E-mail: [email protected]

* 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 Application number Certificate number Certificate issuance date (month, day, year)

APPLICANT Attach two (2) passport type quality photographs of yourself taken within the last eight weeks.

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

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NAME OF SCHOOL

HIGH SCHOOL OR GED EQUIVALENT EDUCATION LOCATION

DATES ATTENDED (month, day, year)

HYPNOTIST EDUCATION NAME OF STATE APPROVED SCHOOL LOCATION DATES ATTENDED (month, day, year)

OTHER EDUCATION AND TRAINING IN THE UNITED STATES OR CANADA NAME OF SCHOOL LOCATION TO FROM (month, year) (month, year) DEGREE

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LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM HYPNOTISM SCHOOL GENERAL LOCATION DATE (month, day, year)

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM HYPNOTISM SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATE (month, day, year)

LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE ANY REGULATED HEALTH OCCUPATION STATE TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR PERMIT NUMBER DATE ISSUED (month, day, year) CURRENT STATUS

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 or civil, 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 certification issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice Hypnotism or any regulated health occupation in any state (including Indiana) or country? 3. Are you now being, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, plead guilty or nolo contendere 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.) 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 other type of discipline or limitations? 6. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign, or retire from any hospital, health care facility or professional association in which you have been associated, trained, held staff membership or privileges, been a member or acted as a consultant? 7. Have you ever had a malpractice judgment or civil action settled against you? Yes Yes Yes Yes Yes Yes Yes No No No No No No No

Yes

No

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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)

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 hypnotist certification. 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, person, institutions any information which is material to my application, and I hereby specifically release the Agency and Committee from any and all liability in connection with such disclosure. 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 the same.
Signature of applicant Date signed (month, day, year)

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