Form Bol-Acu-1 - Acupuncture Application - Idaho Bureau Of Occupational Licenses Page 5
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9ACUPUNCTURE APPLICATION ADDENDUM
(continued)
C. PHOTOGRAPH: Please attach an original passport style photograph of yourself below.
HEIGHT
_____________
WEIGHT
_____________
attach photo here
EYE COLOR
_____________
HAIR COLOR _____________
OTHER DISTINGUISHING FEATURES
D. CURRENT LICENSES AND CERTIFICATIONS: Please list below any licenses, certifications, or other regulatory
credentials ever held, including current status (active, inactive, suspended, revoked, otherwise sanctioned, etc.)
LICENSURE/CERTIFICATION TITLE ___________________________________________________________________
ISSUING ENTITY ______________________________________________________________________________________
DATE ISSUED _________________ CURRENT STATUS ________________ EXPIRATION DATE ________________
IF EVER SANCTIONED, LIST REASON AND SANCTION DISCRIPTION_____________________________________
LICENSURE/CERTIFICATION TITLE ___________________________________________________________________
ISSUING ENTITY ______________________________________________________________________________________
DATE ISSUED _________________ CURRENT STATUS ________________ EXPIRATION DATE ________________
IF EVER SANCTIONED, LIST REASON AND SANCTION DISCRIPTION_____________________________________
LICENSURE/CERTIFICATION TITLE ___________________________________________________________________
ISSUING ENTITY ______________________________________________________________________________________
DATE ISSUED _________________ CURRENT STATUS ________________ EXPIRATION DATE ________________
IF EVER SANCTIONED, LIST REASON AND SANCTION DISCRIPTION_____________________________________
(If more space is needed, attach a separate sheet of paper.)
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BOL-ACU-1 - 04/2010
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