State Form 46715 - Application For Athletic Trainers License

ADVERTISEMENT

APPLICATION FOR
INDIANA ATHLETIC TRAINERS BOARD
ATHLETIC TRAINERS LICENSE
Health Professions Bureau
402 West Washington Street, Room 041
State Form 46715 (R5 / 7-02)
Indianapolis, Indiana 46204
Approved by State Board of Accounts, 2002
Telephone (317) 232-2960
* 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
Application fee
Date fee paid (month, day, year)
APPLICANT
Receipt number
Attach two (2) passport type
quality photographs of yourself
License number
taken within the last eight weeks.
License issuance date (month, day, year)
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden)
Social Security number *
Address (number and street or Rural Route number)
City, state, ZIP code
E-mail address
Telephone number (daytime)
Birthdate (month, day, year)
Birthplace
Applying for licensure by:
Endorsement from another state
Examination
Are you an Indiana resident?
Are you performing athletic training in Indiana more than 180 days per year?
Yes
No
Yes
No
Do you desire a temporary permit?
Yes
No
ATHLETIC TRAINER EDUCATION
Pursuant to Indiana Code 25-5.1-3-1, applicants for licensure as an athletic trainer in the State of Indiana must show completion of the following accredited
courses. Please indicate the institution at which you have completed the required courses. Applicants using NATA approved or CAAHEP accredited
curriculums and applicants using a NATA internship must complete the course information on this form. Applicants must also provide an official
transcript from each institution at which courses were completed or clinical experience was acquired.
Did you complete a NATA approved curriculum?
Name of institution
Yes
No
Type of degree received
Dates attended: (month, year)
Located at (city, state)
From
To
Provide the total number of hours of athletic training experience you have completed under the supervision
of a NATABOC certified athletic trainer while completing the requirements for this degree:
Did you complete a NATA internship?
Name of institution
Yes
No
Type of degree received
Dates attended: (month, year)
Located at (city, state)
From
To
Provide the total number of hours of athletic training experience you have completed under
These hours were completed: (month, year)
the supervision of a NATABOC certified athletic trainer while completing this internship:
From
To
Human anatomy was completed at:
Course title
Course number
Page 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 7