Form Bol-Acu-1 - Acupuncture Application - Idaho Bureau Of Occupational Licenses Page 3
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9ACUPUNCTURE APPLICATION
(continued)
15. Have you ever had any healthcare license, certification, or permit revoked, suspended or otherwise
sanctioned?
[ ]Yes
[ ]No
(If yes, a copy of the charges and the final order must be received by the Board before your application will be processed.)
16. Have you ever been convicted of any State or Federal felony?
[ ]Yes
[ ]No
(If yes, a detailed statement, a summary of the charges, the final order, any probation or parole documentation, and any other relevant
information must be received before your application will be processed.)
Complete and attach the entire ACUPUNCTURE APPLICATION ADDENDUM.
AFFIDAVIT
I hereby certify under oath, that I am the person named in this application for a license, certification or technician
certificate to practice acupuncture in the State of Idaho and; that all statements herein and on the attached addendum are
made as a basis of consideration for the Idaho State Board of Acupuncture to accept and consider as facts which concern
my moral character, pre-professional and professional history and physical and mental qualifications for the rights and
privileges of a license, certification or technician certificate to practice acupuncture in the State of Idaho, all of which are
true and correct; and I voluntarily pledge to refrain from dishonesty or fraudulent methods of acupuncture practice and; I
shall conform to the Rules and Regulations of the Idaho State Board of Acupuncture and the laws of the state of Idaho
and; to refrain from unethical and immoral or unprofessional conduct in my practice and; I shall not by any means make
use of misrepresentations, misleading or untruthful statements to the public or my patients, on my professional cards,
stationery, directories or any other medium and; I hereby agree that the violation of this pledge or any of the provisions of
the Idaho Acupuncture Act shall constitute cause sufficient for suspension, cancellation or revocation of the license,
certification or certificate granted to me.
I also hereby authorize and direct any person, agency, firm, or other entity to release, upon the request of the Bureau of
Occupational Licenses or it’s authorized representative, any information, communication, report, record, statement,
disclosure, or recommendation that may have bearing on my eligibility for or maintenance of the license for which I am
applying. I also hereby authorize the Bureau of Occupational Licenses to release to any other regulatory entity in any
jurisdiction any information requested about me that may be otherwise protected or confidential that may have bearing on
my eligibility for or maintenance of any license issued subsequent to this application.
____________________________________________________
Signature of applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 20 _____.
____________________________________________________
(seal)
Notary Public official signature
my commission expires_________________________________
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BOL-ACU-1 - 04/2010
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