Common use of Applicant’s Attestation Clause in Contracts

Applicant’s Attestation. You must sign and date this for us to process the application. Examination: Professional assistance for test takers with disabilities must submit the request for ADA accommodations to the program 30 days prior to the scheduled exam date. The request must include a written verification from a health care provider. The answer to many frequently asked questions may be found online. We appreciate your interest in obtaining a credential. You will be notified in writing if further documentation is required. If your application is incomplete, you will be mailed or emailed a letter regarding the deficiencies. • The application is considered incomplete if requested information is left blank. Put N/A or place a line through a section instead of leaving it blank. • The initial credential will expire on your birthday unless the credential is issued within 90 days of your next birthday. See WAC 246-12-020(3). • You must keep your address up to date in order to receive a courtesy renewal notice. Any renewal postmarked or presented to the department after midnight on the expiration date is late. For Spouses and Registered Domestic Partners of Military Personnel Being Transferred or Stationed in Washington: Under state law, if you are the spouse or state-registered domestic partner of a servicemember of any branch of the U.S. Military, to include Guard or Reserve, and are applying for a health care professional credential in this state, you may be eligible to have the processing of your application expedited to receive your credential more quickly. Documents to submit with your application should include the following: • A copy of your spouse’s or registered domestic partner’s military transfer orders • One of the following: - A copy of your marriage certificate to show proof of marriage; or - A copy of a state’s declaration or registration showing you are in a state registered domestic partnership with a member of the U.S. military. Please print clearly. It is the responsibility of the applicant to submit or request all required supporting documents be submitted. Failure to do so may result in a delay in processing your application. Select if the following applies: F Spouse or Registered Domestic Partner of Military Personnel 1. Demographic Information Social Security Number (SSN) (If you do not have a SSN, see instructions) National Provider Identifier Number (NPI) (Enter 10 digit number) F Male F Female Name First Middle Last Birth date (mm/dd/yyyy) Address City State Zip Code County Country Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #) Email address Mailing address (if different from above address of record) City State Zip Code County Country Have you ever been known under any other name(s)? F Yes F No If yes, list name(s): Will documents be received in another name? F Yes F No If yes, list name(s): 2. Personal Data Questions Yes No 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? If yes, please attach explanation. .......................................F F “Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction, and alcoholism. If you answered yes to question 1, explain: 1a. How your treatment has reduced or eliminated the limitations caused by your medical condition. 1b. How your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. Note: If you answered “yes” to question 1, the licensing authority will assess the nature, severity, and the duration of the risks associated with the ongoing medical condition and the ongoing treatment to determine whether your license should be restricted, conditions imposed, or no license issued. The licensing authority may require you to undergo one or more mental, physical or psychological examination(s). This would be at your own expense. By submitting this application, you give consent to such an examination(s). You also agree the examination report(s) may be provided to the licensing authority. You waive all claims based on confidentiality or privileged communication. If you do not submit to a required examination(s) or provide the report(s) to the licensing authority, your application may be denied. 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? If yes, please explain. ...................................F F “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally. 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism?...............................................................................................................................................F F 4. Are you currently engaged in the illegal use of controlled substances? ...................................................F F “Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or taken according to the directions of a licensed health care practitioner. Note: If you answer “yes” to any of the remaining questions, provide an explanation and certified copies of all judgments, decisions, orders, agreements and surrenders. The department does criminal background checks on all applicants. 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ...

Applicant’s Attestation. You must sign and date this for us to process the application. Examination: Professional assistance for test takers with disabilities must submit the request for ADA accommodations to the program 30 days prior to the scheduled exam date. The request must include a written verification from a health care provider. The answer to many frequently asked questions may be found online. We appreciate your interest in obtaining a credential. You will be notified in writing if further documentation is required. If your application is incomplete, you will be mailed or emailed a letter regarding the deficiencies. • The application is considered incomplete if requested information is left blank. Put N/A or place a line through a section instead of leaving it blank. • The initial credential will expire on your birthday unless the credential is issued within 90 days of your next birthday. See WAC 246-12-020(3). • You must keep your address up to date in order to receive a courtesy renewal notice. Any renewal postmarked or presented to the department after midnight on the expiration date is late. For Spouses and Registered Domestic Partners of Military Personnel Being Transferred or Stationed in Washington: Under state law, if you are the spouse or state-registered domestic partner of a servicemember of any branch of the U.S. Military, to include Guard or Reserve, and are applying for a health care professional credential in this state, you may be eligible to have the processing of your application expedited to receive your credential more quickly. Documents to submit with your application should include the following: • A copy of your spouse’s or registered domestic partner’s military transfer orders • One of the following: - A copy of your marriage certificate to show proof of marriage; or - A copy of a state’s declaration or registration showing you are in a state registered domestic partnership with a member of the U.S. military. Please print clearly. It is the responsibility of the applicant to submit or request all required supporting documents be submitted. Failure to do so may result in a delay in processing your application. Select if the following applies: F Spouse or Registered Domestic Partner of Military Personnel. 1. Demographic Information Social Security Number (SSN) (If you do not have a SSN, see instructions) National Provider Identifier Number (NPI) (Enter 10 digit number) F ⬜ Male F ⬜ Female ⬜ Prefer not to answer ⬜ X Name First Middle Last Birth date (mm/dd/yyyy) Address City State Zip Code County Country Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #) Email address Mailing address (if different from above address of record) City State Zip Code County Country Have you ever been known under any other name(s)? F ⬜ Yes F ⬜ No If yes, list name(s): Will documents be received in another name? F ⬜ Yes F ⬜ No If yes, list name(s): 2. Personal Data Questions Yes No 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? If yes, please attach explanation. .......................................F F ⬜ ⬜ “Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction, and alcoholism. If you answered yes to question 1, explain: 1a. How your treatment has reduced or eliminated the limitations caused by your medical condition. 1b. How your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. Note: If you answered “yes” to question 1, the licensing authority will assess the nature, severity, and the duration of the risks associated with the ongoing medical condition and the ongoing treatment to determine whether your license should be restricted, conditions imposed, or no license issued. The licensing authority may require you to undergo one or more mental, physical or psychological examination(s). This would be at your own expense. By submitting this application, you give consent to such an examination(s). You also agree the examination report(s) may be provided to the licensing authority. You waive all claims based on confidentiality or privileged communication. If you do not submit to a required examination(s) or provide the report(s) to the licensing authority, your application may be denied. 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? If yes, please explain. ...................................F F ⬜ ⬜ “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally. 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism?frotteurism?...............................................................................................................................................F F ⬜ ⬜ 4. Are you currently engaged in the illegal use of controlled substances? ...................................................F F ⬜ ⬜ “Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or taken according to the directions of a licensed health care practitioner. Note: If you answer “yes” to any of the remaining questions, provide an explanation and certified copies of all judgments, decisions, orders, agreements and surrenders. The department does criminal background checks on all applicants. 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ...⬜ ⬜ Note: If you answered “yes” to question 5, you must send certified copies of all court documents related to your criminal history with your application. If you do not provide the documents, your application is incomplete and will not be considered. If you have been granted certificate(s) of restoration of opportunity, please provide a certified copy of each certificate. To protect the public, the department considers criminal history. A criminal history may not automatically bar you from obtaining a credential. However, failure to report criminal history may result in extra cost to you and the application may be delayed or denied.

Applicant’s Attestation. You must sign and date this for us to process the application. Examination: Professional assistance for test takers with disabilities must submit the request for ADA accommodations to the program 30 days prior to the scheduled exam date. The request must include a written verification from a health care provider. The answer to many frequently asked questions may be found online. We appreciate your interest in obtaining a credential. You will be notified in writing if further documentation is required. If your application is incomplete, you will be mailed or emailed a letter regarding the deficiencies. • The application is considered incomplete if requested information is left blank. Put N/A or place a line through a section instead of leaving it blank. • The initial credential will expire on your birthday unless the credential is issued within 90 days of your next birthday. See WAC 246-12-020(3). • You must keep your address up to date in order to receive a courtesy renewal notice. Any renewal postmarked or presented to the department after midnight on the expiration date is late. For Spouses and Registered Domestic Partners of Military Personnel Being Transferred or Stationed in Washington: Under state law, if you are the spouse or state-registered domestic partner of a servicemember of any branch of the U.S. Military, to include Guard or Reserve, and are applying for a health care professional credential in this state, you may be eligible to have the processing of your application expedited to receive your credential more quickly. Documents to submit with your application should include the following: • A copy of your spouse’s or registered domestic partner’s military transfer orders • One of the following: - A copy of your marriage certificate to show proof of marriage; or - A copy of a state’s declaration or registration showing you are in a state registered domestic partnership with a member of the U.S. military. Please print clearly. It is the responsibility of the applicant to submit or request all required supporting documents be submitted. Failure to do so may result in a delay in processing your application. Select if the following applies: F Spouse or Registered Domestic Partner of Military Personnel. 1. Demographic Information Social Security Number (SSN) (If you do not have a SSN, see instructions) National Provider Identifier Number (NPI) (Enter 10 digit number) F ⬜ Male F ⬜ Female ⬜ Prefer not to answer ⬜ X Name First Middle Last Birth date (mm/dd/yyyy) Address City State Zip Code County Country Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #) Email address Mailing address (if different from above address of record) City State Zip Code County Country Have you ever been known under any other name(s)? F ⬜ Yes F ⬜ No If yes, list name(s): Will documents be received in another name? F ⬜ Yes F ⬜ No If yes, list name(s): 2. Personal Data Questions Yes No 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? If yes, please attach explanation. .......................................F F ⬜ ⬜ “Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction, and alcoholism. If you answered yes to question 1, explain: 1a. How your treatment has reduced or eliminated the limitations caused by your medical condition. 1b. How your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. Note: If you answered “yes” to question 1, the licensing authority will assess the nature, severity, and the duration of the risks associated with the ongoing medical condition and the ongoing treatment to determine whether your license should be restricted, conditions imposed, or no license issued. The licensing authority may require you to undergo one or more mental, physical or psychological examination(s). This would be at your own expense. By submitting this application, you give consent to such an examination(s). You also agree the examination report(s) may be provided to the licensing authority. You waive all claims based on confidentiality or privileged communication. If you do not submit to a required examination(s) or provide the report(s) to the licensing authority, your application may be denied. 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? If yes, please explain. ...................................F F ⬜ ⬜ “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally. 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism?frotteurism?...............................................................................................................................................F F ⬜ ⬜ 4. Are you currently engaged in the illegal use of controlled substances? ...................................................F F ⬜ ⬜ “Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or taken according to the directions of a licensed health care practitioner. Note: If you answer “yes” to any of the remaining questions, provide an explanation and certified copies of all judgments, decisions, orders, agreements and surrenders. The department does criminal background checks on all applicants. 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ...⬜ ⬜ Note: If you answered “yes” to question 5, you must send certified copies of all court documents related to your criminal history with your application. If you do not provide the documents, your application is incomplete and will not be considered. If you have been granted certificate(s) of restoration of opportunity, please provide a certified copy of each certificate. To protect the public, the department considers criminal history. A criminal history may not automatically bar you from obtaining a credential. However, failure to report criminal history may result in extra cost to you and the application may be delayed or denied.