Form Bol-Acu-1 - Acupuncture Application - Idaho Bureau Of Occupational Licenses Page 2
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9STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
700 WEST STATE STREET, PO BOX 83720
Boise, Idaho 83720-0063
ACUPUNCTURE APPLICATION
(see instructions)
I hereby submit my qualifications and make application for: (please check applicable box)
[ ] Licensure
[ ] Certification
[ ] Technician Certification
to practice Acupuncture in the State of Idaho under the provisions of Title 54, Chapter 47, Idaho Code as amended and
provide the following:
1. Full Name (Mr., Mrs., or Ms.) ____________________________________________________________________
2. Full business or trade name _____________________________________________________________
(A business or trade name used by a practitioner shall be registered with the Board within 30 days from the initial use of such name.)
2. Address of Record _____________________________________________________________________________
(The above address is public record)
Street
City
State
Zip
3. Mailing Address________________________________________________________________________________
(The above address is not public record) Street/PO Box
City
State
Zip
4. Date of Birth ___________________ Place of Birth_________________ Social Security No. ________________
mm-dd-yyyy
5. Business phone _________________
Fax __________________ E-mail_____________________________
(The above phone number is public record)
6. Have you ever received formal education or training in acupuncture?
[ ]Yes
[ ]No
(If Yes, official transcripts must be received by the Board directly from the training institution.)
7. Have you ever passed an acupuncture examination or other demonstration of proficiency?
[ ]Yes
[ ]No
(If Yes, official certification of your passing score must be received by the Board directly from the examination administrator)
8. Are you currently or have you ever been licensed or certified to practice acupuncture in any state, country, or
territory?
[ ]Yes
[ ]No
(If Yes, certified documentation must be received by the Board directly from each issuing authority.)
9. Have you completed the requirements for candidacy of or do you hold certification from the National
Certification Commission for Acupuncture & Oriental Medicine or a similar entity?
[ ]Yes
[ ]No
(If Yes, official documentation must be received by the Board directly from said entity.)
10. Have you met the requirements for full membership in the American Academy of Medical Acupuncture or
similar entity?
[ ]Yes
[ ]No
(If Yes, official documentation must be received by the Board directly from said entity.)
11. Have you met the requirements for fellowship in the International Academy of Medical Acupuncture or
similar entity?
[ ]Yes
[ ]No
(If Yes, official documentation must be received by the Board directly from said entity.)
12. Have you met the acupuncture technician requirements of the International Academy of Medical Acupuncture
or similar entity?
[ ]Yes
[ ]No
(If Yes, official documentation must be received by the Board directly from said entity.)
13. Have you completed an acupuncture apprenticeship, internship, or pre-professional practice program?
[ ]Yes
[ ]No
(If Yes, Please list the full name and address of your internship or program supervisor below:)
_________________________________________________________________________________________________
14. Have you ever completed a course on Clean or Sterile Needle Technique?
[ ]Yes
[ ]No
(If Yes, certified documentation must be received by the Board directly from the course provider.)
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BOL-ACU-1 - 04/2010
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