Inactive Status Request Form by xzv69079

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									    South Carolina Department of Labor, Licensing and Regulation
      Board of Examiners in Speech-Language Pathology and Audiology
                                       Intern License Renewal Request Form
The following items are required for renewal:

            Completed intern license renewal request form
            Renewal fee of $110
            Verification of continuing education; 8 hours minimum (.8 ceus)
            PRAXIS scores sent directly from ETS to the Board

Print clearly in black ink or type the following information.

§ 40-67-270. Renewal periods; renewal fee; evidence of continuing education; reinstatement of license

(A) ...A speech-language pathology or audiology intern license may only be renewed for one twelve (12) month
period for the purpose of completing the supervised professional employment required by Section 40-67-220
(B)(1)(c).
I. INTERN DATA

                                                                                                              License #:
Last Name                                    First Name                            Middle Initial


                                                                                                                   (       )
Mailing Address                 City                           State                    Zip Code                           Telephone Number


II. SUPERVISOR DATA

                                                                                                              License #:
Last Name                                    First Name                            Middle Initial


III. EMPLOYMENT DATA (SITE)


Company’s Name                          Mailing Address                          City                              State                   Zip Code


(       )                                                                                                                      /               /
      Telephone Number                                        Practice Setting                                                 Date Internship Began

Specify reason for renewal:
(Attach additional sheets if necessary)




Is there a change in supervision?           [ ] Yes       [ ] No

If yes, a supervisory agreement, intern plan and agreement of supervised professional employment, and an additional fee
of $25 is required.

IV. INTERN STATEMENT

I am aware that upon upgrade, a report of completed internship by each supervisor, a fee of $220, and documentation of 8 hours
of continuing education, which must comply with statutes and regulations, for the current licensure period is required.

______________________________________                                                              ______________________
                    Signature                                                                               Date


                                             Mail all documents to the:
                  South Carolina Board of Examiners in Speech-Language Pathology and Audiology
                                        PO Box 11329 Columbia SC 29211

								
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