Form 46158 - Application For Registration As An Environmental Health Specialist Page 2

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List all states, including Indiana, in which you have been licensed or registered to practice any regulated health occupation.

TYPE OF LICENSE

STATE

NUMBER

DATE ISSUED

CURRENT STATUS

1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held?

Yes

2. Have you ever been denied a license, certificate, registration or permit to practice as an environmental health specialist or any

Yes

regulated health occupation in any state (including Indiana) or country?

3. Are you now, or have you ever been treated for a drug abuse or alcohol problem?

Yes

4. Have you ever been charged with drug addiction?

Yes

5. Have you ever been convicted of, pleaded guilty or nolo contendere to:

Yes

a. A violation of any federal, state or local law relating to the use, manufacturing, distribution or dispensing of controlled

substances or drug addiction?

b. To any offense, misdemeanor or felony in any state (except for minor violations of traffic laws resulting in fines).

Yes

Date (Month, day, year)

Signature of applicant

APPLICATION AFFIRMATION

I hereby swear or affirm under the penalties of perjury,

that the statements made in this application are true,

complete and correct.

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Health Professions

Bureau of Indiana any files, documents, records or other information pertaining to the undersigned requested by the Bureau, or any of its authorized

re pr es e nt a ti ve s in c o nn e ct io n wi th pr oc e s si n g m y a p pl ic a ti o n f or re gi s tra ti o n a s an e n vi ro n me n ta l h e a lth s p ec i al i st .

I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to

such inspection or the furnishing of any such information.

I further authorize the Health Professions Bureau of Indiana to disclose to the aforementioned organizations, persons and institutions any information

which is material to my application, and I hereby specifically release the Bureau and the Board from any and all liability in connection with such disclosures.

A photostatic copy of this application has the same force and effect as the orginal.

Date (Month, day, year)

Signature of applicant

AFFIRMATION

I hereby swear or affirm that I have read the

above statements and agree to same.

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