State Form 46715 - Application For Athletic Trainers License (Page 4 of 7) in pdf

State Form 46715 - Application For Athletic Trainers License Page 4

VERIFICATION OF EDUCATION

TOP PORTION COMPLETED BY APPLICANT

Name of applicant (last, first, middle, maiden)

Address (number and street, city, state, ZIP code)

Date last attended (month, year)

Social Security number or ID number

Signature of applicant

Date of birth (month, day, year)

An appropriate official of the educational institution from which the applicant obtained the required degree must complete the remainder of

this form. The school seal must be imprinted on this form. If there is no school seal, attach letter of explanation on letterhead. The President,

Secretary, Dean, or Registrar of the named institution must sign this form. Return completed from to:

INDIANA ATHLETIC TRAINERS BOARD

402 WEST WASHINGTON STREET, ROOM 041

INDIANAPOLIS, IN 46204

As an official of the school named, I certify that the person named above received a degree as noted after fulfilling all requirements.

Degree received

Date of degree

Signature

Printed name

Title

Name of school

SEAL

If changed, present name

City, state, ZIP code

Date (month, day, year)

APPLICANT: The VERIFICATION OF EDUCATION form must be received before the Indiana Athletic Trainers Board will review your

application. Any processing fees are the applicant’s responsibility. The degree granting institution must send this form directly to the board

at the address listed above.

** PLEASE REQUEST THAT THE SCHOOL ALSO SEND TO THE BOARD AN OFFICIAL COPY OF YOUR TRANSCRIPT.

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State Form 46715 - Application For Athletic Trainers License Page 4