Form 08-4056 - Application For Audiologist License - 2000
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State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Audiology/Hearing Aid Dealer/Speech-Language Pathology Section
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
APPLICATION FOR AUDIOLOGIST LICENSE
Nonrefundable
application fee - $150
Initial license fee - $315
Temporary license - $100
Application for:
Permanent license
Temporary license
Courtesy license - $100
Name
Last
First
Middle
Maiden/Other
Social Security Number
Birthdate
Sex
Mailing Address
City
State
ZIP Code
Residence Address
City
State
ZIP Code
Telephone - Business
Home
Applicants for Temporary Licensure
Please indicate planned dates of practice in Alaska: from
to
EDUCATIONAL HISTORY - List accredited college or university attended where masters or doctorate in audiology
was received; have official transcripts sent directly to Alaska.
Graduate Education
From
To
Degree/Date
Name of School
Location
Mo./Yr.
Mo./Yr.
Awarded
LICENSE HISTORY - List all current and previous audiologist licenses held in any state, territory, or country; have
verifications completed by issuing agencies and sent directly to Alaska. If none, state N/A.
By Examination/
Jurisdiction
License #
Date of Issue
Status
Reciprocity
Department Use Only
License No.
Issue Date
Expiration Date
9/30/
08-4056 (Rev. 8/00)
(1)
CONTINUED ON REVERSE
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