ALABAMA RESPIRATORY THERAPIST LICENSE APPLICATION

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Select Your Type of Application:


Demographics

Last Name
First Name
Middle Name
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(Please upload a 2x2 Passport size photograph that is less than 6 months old)
SSN
DOB
Email
Home Phone
Work Phone
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Mailing Address
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Physical Address
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City
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State
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Education Details

 CREDENTIALS

Credentials
Status
Credentials Expiration


INFORMATION ABOUT EDUCATION

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OTHER STATE LICENSE INFORMATION

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Regulatory Questions

Are you currently charged with, or ever been convicted of a felony or misdemeanor?
Do you have any physical, mental or emotional impairments that would hinder your ability to perform duties assigned in the profession of Respiratory Therapy?  
Are you or have you ever been addicted to alcohol or drugs?
Have you ever been treated for alcohol/substance abuse in a treatment center, hospital, or outpatient setting? If yes, give name of institution, date and length of treatment
Has any state licensing board refused, revoked or suspended a certificate/license issued to you or taken other disciplinary action?
Have you ever voluntarily or otherwise surrendered your Healthcare or Respiratory license or certification/ registry in any jurisdiction, state or territory?
Are you currently under investigation by any healthcare licensing board or agency?
Have you had any malpractice suits filed against you or your employer on your behalf?  

Citizenship

This form to be completed by applicants for licensure in order to comply with Ala. 31-13-7(1975 as amended)



Board Requirements

  In order to process your application, we need the following documents:





Affidavit of Applicant

I authorize and request every person, hospital, clinic, community, governmental agency (local, state, Federal, or foreign), court, association, institution, or any other organization having control of any documents, records or other such information pertaining to me, to furnish to the Alabama State Board of Respiratory Therapy any such documents and records, regarding charges or complaints filed against me formal or informal, pending or closed, or any other pertinent data and permit the Alabama State Board of Respiratory Therapy or any of its agents or representatives to inspect and make copies of such documents, records and other information , in connection with this application, subsequent to practice thereunder.

I authorize and consent to have an investigation made as to my moral character, professional reputation and fitness to practice as a Respiratory Therapist. I agree to give any further information that may be required in reference to my past record. I understand that I will not receive a copy of the report or know its contents and I further understand that the contents of the investigative report will be privileged unless determined otherwise by the Board or a Court Order.

I authorize and request the Alabama Respiratory Therapist to obtain any criminal history information concerning me from any authorized law enforcement agency including but not limited to the Alabama Criminal Justice Information Center, Bureau of Investigation, and the National Crime Information Center (NCIC).

I hereby release, discharge, exonerate, and hold harmless the Alabama Respiratory Therapist or it’s employees, agents, or designees for any and all liability of every nature and kind arising out of the furnishing or inspections of such documents, records or other information or any investigation made by the Alabama State Board of Respiratory Therapy as it relates to me or to this application.

I, acknowledge and state that all of the information supplied in this application is true and correct to the best of my knowledge, that the photograph submitted herein is a true likeness of myself, and that I have read and am familiar with the Rules and Regulations pertaining to the licensure of Respiratory Therapists in the State of Alabama. I acknowledge that any false or untrue statements or representation made in this application may result in the denial or revocation of any license to practice respiratory therapy granted to me and criminal prosecution to the fullest extent of the law.

Background Check Disclosure

      Alabama State Board of Respiratory Therapy (“the Board”) may obtain information about you from a third party background screening companies for licensing purposes.


     These searches will be conducted by Know My Hire, 28577 Hwy. 5 Woodstock, AL | 877.893.5669 | knowmyhire.com


I also understand that iGovSolutions is only a technology provider and the Board is the end-user of the background check.




Fair Credit Reporting Act (FCRA) Rights

WELCOME

Please click here to download the Fair Credit Reporting Act (FCRA) .


Notice Regarding Background Investigation

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

     In connection with your application with (Alabama State Board of Respiratory Therapy) (“Requestor”), notice is hereby given that a consumer report and/or investigative consumer report may be obtained from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or “investigative consumer report” as defined by the Fair Credit Reporting Act (15 U.S.C. § 1681). These reports may contain information about your character, general reputation, personal characteristics and mode of living, whichever are applicable. They may involve personal interviews with sources such as your neighbors, friends or associates. The report may also contain information about you relating to your criminal history, credit history, driving and/or motor vehicle records, social security verification, workers’ compensation claims (after a conditional offer of employment has been made), verification of your education or employment history or other background checks. You have the right, upon written request made within a reasonable time after the receipt of this Notice, to request disclosure of the nature and scope of any investigative consumer report prepared contacting KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188 – Phone: 877.893.5669. For information about KnowMyHire’s privacy practices see www.KnowMyHire.com. The scope of this Notice and Authorization is not limited to the present and, if you are hired will continue throughout the course of your employment and will allow the Requestor to conduct future screenings for retention, promotion or reassignment, as permitted by law and unless revoked by you in writing. The Requestor also reserves the right to share background investigation results with any third-party companies for whom you will be placed to work as a representative of the Requestor. By e-signing below, I acknowledge receipt of above Notice Regarding Background Investigation and a copy of the federal notice entitled, “A Summary Of Your Rights Under The Fair Credit Reporting Act” and certify that I have read both documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Requestor at any time after receipt of this Authorization and throughout the course of my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer or insurance company to furnish any and all background information requested by KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188 – Phone: 877.893.5669, www.KnowMyHIre.com, another outside organization acting on behalf of the Requestor, and/or the Requestor. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as an original.



New York applicants only : You have the right to inspect and receive a copy of any investigative consumer report requested by Requestor by contacting KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188, Phone: 877.893.5669. By e-signing below, you acknowledge receipt of a copy of Article 23-A of the New York Correction Law.

Washington State applicants only : You have the right to request from KnowMyHire a written summary of your rights and remedies under the Washington Fair Credit Reporting Act

Minnesota and Oklahoma applicants only : Please check the box below if you would like to receive a copy of a consumer report if one is obtained by the Requestor.

California applicants only : By e-signing below, you also acknowledge receipt of the “NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW”. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report free of charge, if one is obtained by the Requestor and you have a right to receive such a copy under California Law.



E-Signature : Date : 07/16/2019

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Affirm pay and submit

I understand that I must comply with the provisions of the Alabama Practice Act, Rules of the Board and all other applicable statues and rules.
I affirm that all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action

Date : 07/16/2019

(Board of Respiratory charge will appear as "Respiratory Therapy" and convenience fee will appear as "iGov ePay LLC" on your statement.)

*Amount Due : *Transaction Fee : *Total :
* Person's Name on Card: *Select Debit or Credit : *Card Type :
*Card # : *Expiration Date :
* Security Code :
(Board of Respiratory charge will appear as "Alabama State Board of Respiratory Therapy" and convenience fee will appear as "iGov ePay LLC" on your statement.)
 

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