REINSTATE ALABAMA RESPIRATORY THERAPIST LICENSE APPLICATION

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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
Other Phone
Mailing Address
Zip
City
County
State
Physical Address
Zip
City
County
State
Sex

Education Details

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:

1. Continuing Education Report Form with proof of 24 Hours of Continuing Education (Can’t be more than 24 months old from the date you submit the application)

Click here for the CE report form template



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 State Board of Respiratory Therapy 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 State Board of Respiratory Therapy 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.

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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 : 12/17/2017

(Board of Respiratory charge will appear as "ALA ST BOARD OF RESPIRATORY THERAPIST" 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 "Respiratory Therapy" and convenience fee will appear as "iGov ePay LLC" on your statement.)
 

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