Audiology Application Instructions (including Asha Or Aba Waiver)


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AUDIOLOGY APPLICATION INSTRUCTIONS (INCLUDING ASHA OR ABA WAIVER)
DOCUMENTS SUBMITTED WITH YOUR APPLICATION WILL NOT BE RETURNED. KEEP A COPY OF YOUR COMPLETED APPLICATION, ALL ATTACHMENTS, AND YOUR CHECK OR MONEY ORDER.
1. NAME – Provide your legal name in the spaces provided. (Last Name, First Name, Middle Name, Suffix) Examples of a suffix include Jr., Sr., and III. (Mr. is not a suffix.)
2. NAME ON TRANSCRIPT(S) – If the name is different from item 1, complete this field.
3. DATE OF BIRTH – Provide your birthdate.
4. SOCIAL SECURITY NUMBER – Social security number disclosure is required by Section 231.302(c)(1) of the Texas Family Code in order to obtain a license. Your social security number is subject to disclosure to an agency authorized to assist in the collection of child support payments. For more information regarding child support payments, contact the Texas Attorney General or call (512) 460-6000 or (800) 252-8014
5. EMAIL ADDRESS – Provide your email address only if you agree to the following statement. By providing my email address I authorize the Texas Department of Licensing and Regulation (TDLR) to send licensing communications and required notices to me by electronic mail. I understand that I may revoke this authorization in writing and that I must update my email address, or I will not receive these notices. I understand that the email address I have provided in this application will remain confidential except as permitted or required by law.
6. PERSONAL PHONE NUMBER – Provide a telephone number, including the area code, where we can reach you during the day. This may be your office phone number where we can leave a message.
7. BUSINESS PHONE NUMBER – Provide the telephone number, including the area code, of the business listed.
8. MAILING ADDRESS – Provide your current mailing address. This is the address where we will send you mail. This address can be a post office box. You can add the zip plus-4 to help the postal service deliver mail more efficiently and accurately.
9. POSSESS A PROFESSIONAL LICENSE, OR CERTIFICATE, OR REGISTRATION ISSUED BY ANOTHER STATE, JURISDICTION OR TERRITORY – Indicate by checking box Yes or No. If yes, a license verification form must be completed by the state regulatory agency in each state from which you hold or ever held a license to practice. Give license or certificate number(s), title(s), and the name(s) and address (s) of the jurisdiction(s) issuing the license(s), or certificate(s), or registration(s).
10. DISCIPLINARY ACTION HISTORY – Indicate if you have ever had a professional license, certification, or registration suspended, canceled, revoked, or denied in any state. If you have, complete and attach a Disciplinary Action Questionnaire (PDF) for each disciplinary action.
11. VOLUNTARILY SURRENDERED ANY PROFESSIONAL LICENSE, OR CERTIFICATE, OR REGISTRATION – Indicate by checking the box Yes or No. If yes, briefly describe.
12. CURRENT EMPLOYMENT – Please list the contact information for your current employer.
13. ACADEMIC TRAINING – List all colleges and universities attended and attach additional pages if necessary.
14. CRIMINAL HISTORY – Indicate if you have ever been convicted of, or placed on deferred adjudication for, any Misdemeanor or Felony, other than a minor traffic violation. If YES, complete and attach a Criminal History Questionnaire (PDF) for each offense. If you are worried your criminal history could prevent you from getting this license, Texas allows you to have your criminal history evaluated before submitting your application and non-refundable fees. To request a criminal history evaluation, submit a Criminal History Evaluation Letter (PDF), a completed Criminal History Questionnaire (PDF) for each crime you were convicted of, or placed on deferred adjudication for, and a $10.00 fee.

TDLR Form SPA005 August 2021

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REQUIRED FOR ALL NEW APPLICANTS: Fingerprinting: All new applicants must submit fingerprints for a national criminal history record review. The applicant is responsible for paying the fee associated with this review to the fingerprint service vendor used by Texas Department of Public Safety. Once your completed application is received by TDLR, instructions on how to schedule an appointment to be fingerprinted will be emailed to you. Be sure your email address is current and legible to receive the fingerprinting information. To be eligible for licensing, you must successfully pass a criminal history background check. If you submitted fingerprints for a Texas speech-language pathology assistant license or a Texas intern in speech-language pathology license, you do not need to submit fingerprints again.
15. STATEMENT OF APPLICANT - Carefully read the statement before dating and signing your application.
CHECKLIST OF REQUIRED DOCUMENTATION TO BE SUBMITTED WITH APPLICATION AND FEE:
Submit your original or certified copy of the transcript(s) showing a doctoral degree has been conferred and required audiology course work. The transcript cannot be faxed. Electronic university transcript(s) will be accepted if emailed to [email protected] from the university’s secure site. We donot accept electronic transcripts from the applicant. Texas Jurisprudence Exam. Please submit a copy of your certificate of completion. This is a no fail exam over the rules and laws.
Current Texas intern in audiology license holders:
Report of Completed Audiology Internship Form. If the applicant currently holds a Texas intern in audiology license, a Report of Completed Audiology Internship Form, completed by the applicant’s department-approved supervisor and signed by both the applicant and the department-approved supervisor.
Out-of state intern in audiology license applicants:
A copy of the supervisor’s diploma or transcript showing a master's or doctoral degree in communicative sciences or disorders; and One of the following: if that state requires licensure, a copy of the supervisor’s valid license to practice in that state or if that state does not require licensure, an original letter from ASHA stating the supervisor held the Certificate of Clinical Competence when the applicant completed the internship.
If applying for licensure by ASHA Certificate of Clinical Competence or the ABA Certification, please submit:
An original or certified copy of a signed letter from ASHA or ABA which verifies the applicant currently holds the ASHA Certificate of Clinical Competence or ABA Certification in the area of audiology.
An original or certified copy of the transcript(s) showing the conferred degree of all relevant course work which also verifies that the applicant possesses a minimum of a doctoral degree in audiology or a related hearing science; however, an applicant whose transcript is in a language other than English shall submit an original evaluation form from an approved credentialing agency.
The Texas Jurisprudence Exam certificate of completion, proof of fingerprint submission, and fees.

TDLR Form SPA005 August 2021

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APPLICATION INFORMATION FOR MILITARY SERVICE MEMBERS, MILITARY VETERANS AND MILITARY SPOUSES The Texas Department of Licensing and Regulation recognizes the contributions of our active-duty military service members, their spouses, and veterans. If you want to use one of the licensing options available to military service members, military veterans and military spouses, please complete the Military Service Member, Military Veteran or Military Spouse Supplemental Application (PDF) and attach it with your license application.
If you have additional questions about qualifications, training or experience requirements relating to occupation licensing for military service members, military veterans or military spouses please go to the TDLR Military Informationweb page.
SEND YOUR COMPLETED APPLICATION AND REQUIRED DOCUMENTS TO:
TDLR P.O. Box 12157 Austin, TX 78711-2157
Documents submitted with your application will not be returned. Keep a copy of your completed application, all attachments, and you check or money order. Do not send cash.
For additional information and questions, please visit the TDLR website. You can request assistance or submit required attachments via TDLR webform or fax (512) 463-9468. You may contact Customer Service Representatives by calling (800) 803-9202 (in state only) or (512) 463-6599; Relay Texas -TDD (800) 735-2989. Customer Service Representatives are available Monday through Friday from 7:00 a.m. until 6:00 p.m. Central Time (excluding holidays).
TDLR Public Information Act Policy: This document is subject to the Texas Public Information Act. With certain exceptions, information in this document may be made available to the public. For more information, view the TDLR Public Information Act Policy.

TDLR Form SPA005 August 2021

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AUDIOLOGY APPLICATION (INCLUDING ASHA OR ABA WAIVER)
APPLICATION FEE: $150.00 (FEE IS NON-REFUNDABLE) This completed form must be accompanied by all required documents and the application fee.
1. Name:

Last, First, Middle Name, Suffix (Jr., Sr., III)
2. Name on diploma/transcript(s): (if different from #1)

3. Date of Birth:

Last, First, Middle Name
4. Social Security Number:

Month/Day/Year
5. Email Address:

See Instruction Sheet for Disclosure Information

6. Personal Phone Number:

7. Business Phone Number:

Ex: [email protected] See Instruction Sheet for Disclosure Information
8. Mailing Address:

(Area Code) Phone Number

(Area Code) Phone Number

P.O. Box, Number, Street Name/Apartment Number&LW\6WDWH=LS&RGH

9. Do you possess professional license(s), certificate(s), or registration(s) issued by another state state(s), jurisdiction, or territory?

Yes No

If yes, a license verification form must be completed by the state regulatory agency in each state from which you hold or ever held a

license to practice. Give license, or certificate, or registration number(s), title(s), and the name(s) and address(s) of the

jurisdiction(s) issuing the license(s), or certificate(s), or registration(s).

10. Have you ever had a professional license, certification or registration suspended,
If YES, complete and submit a Disciplinary Action Questionnaire (DAQ) with this application. This does not include your driver license.

Yes No

11. Have you ever voluntarily surrendered any professional license, or certificate, or registration?
If answer is yes, briefly state the type of license, or certificate, or registration, the name and address of the agency that issued the license, or certificate, or registration, and the reasons.

12. Place of Employment:

CURRENT EMPLOYMENT CONTACT INFORMATION Phone Number:

Yes No

Employer's Address:

(Area Code) Phone Number

Job Title:

Street Number, Street Name, Suite Number, City, State, Zip Code
Employment Start Date:
Month/Day/Year

TDLR Form SPA005 rev August 2021

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13.

ACADEMIC TRAINING

(List all high schools, colleges, and universities attended and attach additional pages if necessary)

Name of High School/College/University/Institution:

Location:

Inclusive dates attended:

Street Number, Street Name, City, State, Zip Code

Begin (Month/Year)
Type of Degree Granted:

Major Field:

End (Month/Year)

Name of High School/College/University/Institution:

Location:

Inclusive dates attended:

Street Number, Street Name, City, State, Zip Code

Begin (Month/Year)
Type of Degree Granted:

Major Field:

End (Month/Year)

14. Have you ever been convicted of, or placed on deferred adjudication for, any misdemeanor or felony, other than a minor traffic violation?
If YES, complete and submit a Criminal History Questionnaire (CHQ) for each offense.
Once your completed application is received, instructions on how to schedule an appointment to be fingerprinted will be emailed to you. Be sure your email address is current and legible to receive the fingerprinting information. See instructions sheet for more information.

Yes No

15.

STATEMENT OF APPLICANT

I certify that I have read and will comply with all applicable provisions of the Speech-Language Pathology and Audiology Act; Texas Occupation Code, Chapter 401 and Chapter 51; Texas Administrative Code, Chapter 111; and the SpeechLanguage Pathology and Audiology Administrative Rules, I understand that providing false information on this application may result in denial of this application and/or revocation of the license I am requesting and the imposition of administrative penalties.

Signature of Applicant

Date Signed

TDLR Form SPA005 rev August 2021

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Audiology Application Instructions (including Asha Or Aba Waiver)