STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
OWYHEE PLAZA
1109 MAIN STREET, SUITE 220
BOISE, IDAHO 83702-5642 

EDUCATION APPROVAL APPLICATION 

This is a "request for approval" application for entry education or continuing education offerings not otherwise approved by the Board. It must be completed in its entirety. If additional space is needed, add separate pages and note the corresponding item number on your response.  Please use a separate form for each course.  All advertisement brochures and/or promotional materials if used, must accompany the application.  A course syllabus or outline, together with a copy of all training materials, and a third party notarized letter verifying the instructor's qualifications and affiliations must also accompany this application.  Applications must be received well before the date the course is offered to allow the Board adequate time to review the materials. Check the applicable Idaho Law or Rule for deadline restrictions. The Board may deny credit for any course that does not meet the requirements of Idaho Law or Rule. Review the requirements before submitting your request.

Name of Course or Seminar: 

Relevant Profession(s):

1.  Sponsoring Organization or Institution:

2. Applicant Contact information:

    Name: 

    Phone:    Fax:    E-mail:

    Address:  

    City:          State:         Zip:

3. Name of cosponsor (if applicable): 

4. Date(s) course will be offered (from - to):                                             Locations:

5. Fee to be charged:  $  Fee includes: 

6. What best identifies the educational experience? 
Lecture    Convention      Forum    Workshop    Home Study    Distance Learning   

     Other: 

7. Exact hours per day the course is scheduled to run (list hours for each day of multi-day courses): 

8. Number of education hours requested for the course: CE clock hours &/or  CEUs  &/or  Pre-licensure hours

9. List name(s) of instructors (attach qualifications, including education, experience, & license #s for each name, and a letter verifying each instructor's qualifications that is signed by a third party and notarized.):

10. Provide name of attendance officer and method of certifying/assuring attendance and who maintains original attendance records for verification?
(Attach a copy of the attendance certificate that will be provided to each attendee. The licensee is required to maintain proof of attendance.)

11. Is an examination part of the course?                                                             YES         NO
If YES, attach a description of the process.

12. Is a course evaluation form provided to attendees?                                        YES         NO
If YES, attach a copy of the form.

13. Will the same instructor(s) be presenting this course more than once?             YES           NO  

14. Has this course been approved for education or continuing education credit by any local, state, or national entity?   
                                                                                                                            YES            NO  
     If YES, enter name of approving entity and attach a copy of the approval document:                          

15.Attach a copy of all training materials, texts, videos, CDs, tapes, and a list of any equipment to be used.  (Materials will be returned by request only after a course has been approved.)

16.Are any promotional publications or advertisements being used?                    YES          NO
If YES, please attach one copy of each (final drafts are acceptable).  

17.Does this course either promote a product or apparatus or offer a product or apparatus to those attending?
                                                                                                                YES          NO
If YES, this must be explained on a separate attachment to this application and disclosed in any advertising.

18. Will those attending be given a product as a gift or at a reduced price?           YES          NO
            If YES, please explain on a separate attachment to this application.

Upon completion, this application must be printed in hard copy and signed and notarized. Submit the completed application together with all of the requested supporting documentation to the Bureau of Occupational Licenses at the address noted.

AFFIDAVIT

 I hereby certify that all information listed on this application and on the attached material is true and correct; that the proposed training is described accurately and completely; and that nothing has been omitted.  I understand that the Board may request additional information and may delay or deny this application should requested information not be received.

Print name:       Title     

                                                                                       ___________________________________
                                                                           Signature: 

State of _____________,  County of __________________, ss

Subscribed and sworn before me this _________ day of ___________________, 20___.

                                                                                       ___________________________________
                                                                           Notary Public Official Signature 
     (seal)                                                              my commission expires _____________

Last Modified - Friday, February 23, 2007