20:60:05:05.  Application forms. To qualify for licensure under SDCL chapter 36-27A, the applicant shall complete and submit to the board an application form supplied by the board. The form shall contain the following information:

          (1)  Name, address, and telephone number;

          (2)  Date and place of birth;

          (3)  A description of licenses held in other states;

          (4)  A request for endorsement, if applicable;

          (5)  Date and circumstances of previous national standardized examination;

          (6)  A statement of any psychology licensure denied;

          (7)  A statement of any professional sanctions as a psychologist;

          (8)  A statement of any criminal record;

          (9)  A statement of education and training;

          (10)  Official transcripts of education;

          (11)  A description of internship;

          (12)  A description of professional experience;

          (13)  Compliance with SDCL 36-27A-12 unless exempted; and

          (14)  Notarized signature of applicant.

          Source: 8 SDR 92, effective February 3, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 18 SDR 74, effective October 30, 1991; 20 SDR 14, effective August 11, 1993.

          General Authority:SDCL 36-27A-21.

          Law Implemented:SDCL 36-27A-21.