Form 46158 - Application For Registration As An Environmental Health Specialist
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4APPLICATION FOR REGISTRATION
HEALTH PROFESSIONS BUREAU
AS AN ENVIRONMENTAL HEALTH SPECIALIST
Indiana Government Center South
402 W. Washington St., Rm 041
State Form 46158 (7-93)
Indianapolis IN 46204
Approved by State Board of Accounts 1993
Telephone Number (317) 232-2960
* Your Social Security number is being requested by this state agency in accordance with I. C. 4-1-8-1.
Disclosure is mandatory, and this record cannot be processed without it.
APPLICANT
OFFICE USE ONLY
Attach one (1) passport quality
photograph of yourself taken
Application fee
Issuance fee
within the last eight weeks
$
$
Date fee paid (Month, day, year)
Registration number
Receipt number
Issuance date
APPLICANT INFORMATION
Name (Last, first, middle, maiden)
Social Security number *
Address (Number and street, or rural route)
City, state, ZIP code
Telephone number (Daytime)
Birthdate (Month, day, year)
Birthplace
Are you applying for registration by:
Endorsement
Examination
PROFESSIONAL EDUCATION
Name of school
Date of graduation (Month,day, year)
Address (Number and street, city, state, ZIP code)
Degree
Name of school
Dates attended
Address (Number and street, city, state, ZIP code)
Name of school
Dates attended
Address (Number and street, city, state, ZIP code)
EXAMINATION RECORD
National Examination
If yes, how many times ?
Date of most recent test (Month, year)
Where taken (State or country)
Do you hold, or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation ?
Yes
No
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