Form 08-4056 - Application For Audiologist License

PROFESSIONAL FITNESS - If the answer to any of the following questions is “Yes,” explain fully in a separate,

signed affidavit. “Yes” answers may not automatically result in license denial.

YES

Has your professional license been denied, revoked, suspended, surrendered,

stipulated, on probation, or been subject to any other restriction or disciplinary

action in any jurisdiction? .......................................................................................................

Have you voluntarily surrendered or restricted your professional license

in any jurisdiction? ..................................................................................................................

Have you ever been disciplined for any violation or unethical conduct? ...............................

Have you been convicted of a felony or misdemeanor, other than minor

traffic violations, under the laws of any local, state, or federal jurisdiction

of the United States or any other country? ............................................................................

Within the past five years, have you experienced or been diagnosed with,

or treated for bipolar disorder, schizophrenia, paranoia, psychotic disorder,

substance abuse, depression, or any other mental or emotional illness?.............................

Within the past five years, have you experienced, been diagnosed with, or,

been treated for any physical or mental condition which may impair or

interfere with your ability to practice? .....................................................................................

Within the past five years, have you experienced, been diagnosed with, or

been treated for any chemical impairment?...........................................................................

If you answered “Yes” to any of the above questions, please explain dates and circumstances on a separate piece

of paper, and send any supporting documents that are applicable (court records, etc.).

Please be advised that all information provided with this application will be available to the public unless required

to be kept confidential by state or federal law.

I certify that the information in this application is true and correct to the best of my knowledge. I further certify

that all credentials and supporting documents supplied by me are true and correct and that the photograph which

appears below is a true likeness of me taken within the past 60 days. I understand that any false information or

falsification of documents may result in failure to obtain, or subsequent revocation of, a license to practice audiology

in Alaska.

Sign Here

Signature of Applicant

SUBSCRIBED AND SWORN TO before me on

(date).

CURRENT HEAD AND

SHOULDERS PHOTOGRAPH

Notary Public, State of

My Commission Expires:

(NOTARY SEAL)

NOTE: NOTARY PUBLIC SEAL MUST OVERLIE A PORTION OF THE PHOTOGRAPH

08-4056 (Rev. 8/00)

(2)

Form 08-4056 - Application For Audiologist License - 2000 Page 2