Kan. Admin. Regs. § 100-69-12

Current through Register Vol. 43, No. 49, December 5, 2024

Section 100-69-12 - Application

(a) Each applicant for li-censure as an athletic trainer shall submit a completed application on a form provided by the board. The application shall include the following information in legible writing:

(1) The applicant's full name;

(2) the applicant's mailing address. If the applicant's mailing address is different from the applicant's residential address, the applicant shall also provide the residential address;

(3) the applicant's social security number, driver's license number, nondriver identification number, or individual tax identification number if the applicant is advised that providing a social security number is voluntary pursuant to K.S.A. 74-139 and 74-148, and amendments thereto, and that if the social security number is provided, the agency may provide this number to the Kansas department of social and rehabilitation services for child support enforcement purposes and to the Kansas department of revenue's director of taxation;

(4) information on any licenses, registrations, or certifications issued to the applicant to practice any health care profession;

(5) information on any prior acts constituting unprofessional conduct, as defined in K.A.R. 100-69-7, that could constitute grounds for denial of the application;

(6) the applicant's daytime telephone number;

(7) the applicant's date and place of birth;

(8) the name of each educational program recognized under K.A.R. 100-69-1 that the applicant attended, including the program from which the applicant graduated, the degree awarded to the applicant, and the date of graduation;

(9) the number of times the applicant has taken the examination required by the board for licensure and the date that the applicant passed the examination; and

(10) a notarized release authorizing the board to receive any relevant information, files, or records requested by the board in connection with the application.

(b) Each applicant shall submit the following with the application:

(1) The fee required by K.A.R. 100-69-5 ;

(2) an official transcript that specifies the degree awarded from an educational program recognized by the board under K.A.R. 100-69-1 ;

(3) a verification on a form provided by the board of each license, registration, or certification issued to the applicant by any state or the District of Columbia relating to any health care profession;

(4) a current photograph, two by three inches in size, of the applicant's head and shoulders taken within 90 days before the date the application is received by the board; and

(5) evidence provided directly to the board from the testing entity recognized and approved under K.A.R. 100-69-3 that the applicant has passed the examination.

(c) The applicant shall sign the application under oath and have the application notarized.

Kan. Admin. Regs. § 100-69-12

Authorized by K.S.A. 2008 Supp. 65-6905; implementing K.S.A. 2008 Supp. 65-6906; effective June 4, 2010.