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.  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 for any course listed, and a resume' listing the instructor's qualifications and affiliations  must also accompany this application.  Applications must be received well before the offering date to allow the Board adequate time to review the materials. Check the applicable Board Laws and Rules for applicable deadlines. The Board may deny credit for any course that does not meet the requirements of Idaho Law or Rule. Please review the requirements before submitting your request.

Course, Seminar or Conference Title: 

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) and Locations of offerings:             
             From                    To                            Locations:

5. Fee to be charged:  $  Fee includes: 

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

     Other: 

7. Provide the name of attendance officer, and the 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.)

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

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

10. 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:                          

11.Attach a course agenda, 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.)

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

13.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.

14. 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.

COURSE ADDENDUM

Complete the Course Program Addendum by listing the name(s) of instructor(s), exact hours per day each course is scheduled to run, the CEU’s (or clock hours), whether a course is relevant to one or more specific disciplines or license types, and whether or not approval for Pre-Licensure credit is being requested.

An instructor resume' and course agenda must be submitted for each instructor and course listed. 

   Instructor Name        Course Title                                                    Hrs. CEUs     Relevancy

If you need additional space for more courses, please attach a separate listing that includes the requested information.)

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.

EDUCATION APPROVAL APPLICATION 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 - Thursday, October 16, 2008