Arkansas Board of Examiners Speech-Language Pathology and Audiology

APPLICATION FOR LICENSURE

ARKANSAS BOARD OF Examiners in Speech-Language Pathology and Audiology, Arkansas Board

APPLICATION FOR LICENSURE

All candidates for licensure have an obligation to update and supplement the information and responses on this application if they change. Failure to supplement the information and response provided on this application may result in denial or other appropriate action. Your application will not be considered complete until all documents and fees have been received by the Board office.

Please contact the Board office at (501) 537-9151 if you have any questions.

* = REQUIRED
RACE*:
Have you ever held an Arkansas Speech-Language Pathology or Audiology License?
Please list any state(s) in which you currently hold a professional license, if any:
Do you hold current certification with American Speech-Language Hearing Association (ASHA) or the American Board of Audiology (ABA)?
EDUCATION
CLEAR FIRST COLLEGE INFORMATION
MM/DD/YYYY
ATTESTATATIONS

ANSWER EACH STATEMENT YES OR NO - ALL MUST BE ANSWERED

Have you ever been the subject of disciplinary action (e.g., revocation, suspension, reprimand, fine, etc.) by a state licensing authority?
NOTE: If you answer "Yes", you will need to send in an explanation with your other documents.

Do you have any unresolved or pending complaint(s) or disciplinary action against you or your professional licensure?
NOTE: If you answer "Yes", you will need to send in an explanation with your other documents.

Have you ever voluntarily surrendered your professional license in any state?
NOTE: If you answer "Yes", you will need to send in an explanation with your other documents.

Has any state licensing authority ever denied your application for licensure or renewal?
NOTE: If you answer "Yes", you will need to send in an explanation with your other documents.

Have you ever been charged or convicted of any crime, not including minor traffic offenses?br>NOTE: If you answer "Yes", you will need to send in an explanation with your other documents.

Are you or your spouse a Uniform Service Member or Veteran?

First expected day of practice in Arkansas will be:
SIGNATURE & SUBMIT
CHECK THE SIGNATURE BOX TO SUBMIT YOUR INFORMATION