Free 50694.FH11 - Indiana

APPLICATION FOR LICENSURE AS AN ACUPUNCTURIST / PROFESSIONAL ACUPUNCTURIST
State Form 50694 (R / 2-06) Approved by State Board of Accounts, 2006

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INDIANA ACUPUNCTURE ADVISORY COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2060 E-mail: [email protected] www.pla.IN.gov

* 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 LICENSE NUMBER DATE LICENSE ISSUED (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 (last, first, middle) Current address (number and street or rural route) City, state, and ZIP code Permanent address (if different from address above) City, state, and ZIP code Telephone number (daytime) E-mail address Birthplace Social Security number *

(

)

Date of birth (month, day, year)

BASIS FOR LICENSURE Acupuncturist (holding no other professional license) Current Diploma of NCCAOM Licensed Chiropractor Licensed Dentist Licensed Podiatrist Other
IN license number IN license number IN license number Expiration date (month, day, year) Expiration date (month, day, year) Expiration date (month, day, year)

ACUPUNCTURE DEGREE GRANTED BY
Name of school Location Is this program approved by the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine? If No, please explain: Date of graduation (month, year)

Yes

No

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CHIROPRACTIC / DENTAL / PODIATRIC DEGREE GRANTED BY
Name of school Location Have you completed 200 hours of acupuncture training in an approved college / university? Date of graduation (month, year)

Yes If Yes, please list in box below. No If No, please explain:

ACUPUNCTURE TRAINING FOR DENTISTS, CHIROPRACTORS AND PODIATRISTS (Please list a minimum of 200 hours of Acupuncture Training) NAME OF PROGRAM LOCATION TITLE # OF HOURS

NAME OF SCHOOL

OTHER EDUCATION AND TRAINING IN THE UNITED STATES LOCATION FROM (month, year)

TO (month, year)

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM ACUPUNCTURE, CHIROPRACTIC, DENTAL OR PODIATRY SCHOOL GENERAL LOCATION DATE (month, day, year)

LIST ALL PLACES YOU HAVE WORKED SINCE GRADUATION FROM ACUPUNCTURE, CHIROPRACTIC, DENTAL OR PODIATRY SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATE (month, day, year)

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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 it is a malpractice settlement or judgment against you, please provide name(s) of plaintiffs, case summary, settlement amount and include court documents, if applicable. 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. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held in any state? 2. Have you ever been denied a license, certificate, registration or permit to practice medicine, osteopathic medicine 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 arrested, 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. 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 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? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? 8. Have you ever been the subject of an investigation by a regulatory agency concerning a license? 9. Have you ever surrendered or had limitations placed on your DEA registration at any time? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No 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 applicant Date signed (month, day, year)

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AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, 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 their authorized representatives in connection with processing my application for acupuncture licensure. 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 Indiana Acupuncture Advisory 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 applicant Date signed (month, day, year)

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