a. Affadavit: If you answer "yes" to any
question on page 2 of your application, explain fully in a signed and notarized
statement, including all related details. Include the violation, location,
date and disposition. If malpractice,
provide name(s) of plaintiff(s). Letter from attorneys or insurance companies are not accepted in lieu of your
statement.
b. Fee Information: A one-hundred fifty dollar ($150) application fee,
made payable to IPLA. Checks or Money Orders are acceptable. All fees are non-refundable
and non-transferable.
c. Photograph: One (1) passport-type quality photograph of yourself taken
within the last eight (8) weeks.
d. Certificate of Clinical Competence from ASHA: A current certificate of clinical competence (CCC's) from the
American Speech-Language Hearing Association may be submitted for the
following requirements:
1. transcript
2. direct supervised clinical experience,
3. clinical fellowship
4. official scores
You may submit a notarized photocopy of either the certificate itself or an original letter from ASHA indicating
completion of all requirements. Thecertificate must have a current expiration date.
e. Official Transcript: An official transcript of grades from the
speech-language pathology or audiology school
certifying that the applicant possesses a master's degree or it's equivalent
from an accredited institution in the
area for which the applicant is applying for licensure.
f. Direct Supervised Clinical Experience: Certification from the educational institution that the applicant has
completed three hundred (300) hours of direct supervised clinical experience.
g. Certification of completion of clinical fellowship, which meets requirements of
IC 25-35.6-1-5(5) and 880 IAC 1-1-3. Submit to the Board evidence of
completion of at least nine (9) consecutive months, at no less than thirty (30)
hours per week, of clinical experience in which the professional area (speech-language pathology or
audiology) for which a license is sought.
h. Official Scores: Request that your official scores be sent directly to the
Bureau from ETS. Contact ETS for
information regarding how to obtain your scores and the fee information.
Contact ETS at:
ETS-Praxis Series
PO Box 6052
Princeton, NJ 08541-6052
1-800-772-9476
