Applied Behavioral Analyst (LBA) Applied Behavioral Assistant Analyst .

***FOR OFFICE USE ONLY******FOR OFFICE USE ONLY***License Number:ChecklistIssue Date:App. & FeeDate: CheckProof of BACB CertificationBackground Check (BCI)Lic. Verification from other StatesApproved for Licensure:Signature of Board MemberPsychologists ONLY:Curriculum Summary FormTranscriptSignature of Board AdministratorRhode IslandApplied Behavior AnalystLicensing BoardID#:Receipt #:Room 1043 Capitol HillProvidence, RI 02908-5097Instructions and Application ForLicense As AApplied Behavioral Analyst (LBA)Obtained By:BACB CertificationNameLicense #Applied Behavioral Assistant Analyst (LABA)RI PsychologistPSRI License Number:MILITARY STATUS ELIGIBILITY(Documentation Required)see next page for instructionsPlease check ONE of the following criteria for expedited application:I am in active military duty or a reservistI am a military veteran with honorable dischargeI am the spouse of someone in active military duty or the spouse of a reservistApplicant - Print NameLAST NAMEPhone: (401) 222-2828FIRST NAMETTY/TDD: (800) 745-5555MIFax: (401) 222-1272Revised 08/01/2018 jcp

APPLICATION INFORMATIONChecklist for Obtained By BACB CertificationCompleted Application with Cover Page - Applications are valid for 1 year from the day they are received atRIDOH. If you are not licensed within the year you must submit a new application.Check or money order (preferred), made payable (in U.S. funds only) to the RI General Treasurer in the amountof 150.00 and attached to the upper left-hand corner of the first (Top) page of the application.THIS APPLICATION FEE IS NONREFUNDABLEProof of Behavior Analyst Certification from BACB (Behavioral Analyst Certification Board)BCI - (Criminal Background Check) An original BCI obtained within the previous 6 months of application. Youmust apply to the Department of the Attorney General. For information please visit their website at:http://www.riag.ri.gov/BCIIf you have ever been licensed in another state, license verification(s) must be sent directly from the state(s) inwhich you hold or have held a license. (Interstate Verification Form included in this application can be used forthat purpose)Checklist for Obtained By RI PsychologistCompleted, Notarized Application with Cover Page - Applications are valid for 1 year from the day they arereceived at RIDOH. If you are not licensed within the year you must submit a new application.Check or money order (preferred), made payable (in U.S. funds only) to the RI General Treasurer in the amountof 150.00 and attached to the upper left-hand corner of the first (Top) page of the application.THIS APPLICATION FEE IS NONREFUNDABLEActive Rhode Island Psychologist LicenseOfficial Transcript sent directly from the accredited school sent directly to the Board. No student copies will beaccepted.BCI - (Criminal Background Check) An original BCI obtained within the previous 6 months of application. Youmust apply to the Department of the Attorney General. For information please visit their website at:http://www.riag.ri.gov/BCIIf you have ever been licensed in another state, license verification(s) must be sent directly from the state(s) inwhich you hold or have held a license. (Interstate Verification Form included in this application can be used forthat purpose)Curriculum Summary Form, provided in this application.Note: If applying for expedited military status you must include one of the following: Leave Earning Statement(LES), Letter from Command, Copy of Orders or DD-214 showing honorable discharge.Licensure InformationPlease visit the RIDOH website at http://www.health.ri.gov/licenses to Verify your license, download Rulesand Regualtions/Laws for your profession, download change of address forms, other licensing forms or obtainour contact information.HEALTH will not, for any reason, accelerate the processing of one applicant at the expense of others.License CertificatesRIDOH will be providing wallet license cards ONLY on issuance of licenses. If you wish to receive a licensecertificate, suitable for framing, please check the box below and attach a separate check in the amount of 30.00 made payable to RI General Treasurer.I would like to receive a license certificate. I have enclosed a separate check in the amount of 30.00Rhode Island Applied Behaviorial Analyst Licensing Board - Page 2

State of Rhode Island and Providence PlantationsApplied Behavior Analyst Licensing BoardRefer to the Application Instructions when completing these forms. Type or block print only. Do not use felt-tip pens.1. Name(s)This is the name thatwill be printed on yourLicense/Permit/Certificate and reportedto those who inquireabout your License/Permit/Certificate. Donot use nicknames, etc.Title (i.e., Mr., Mrs., Ms., etc.)NOTE:It is your responsibility to notify theDepartment of HealthBoard of any namechanges.Surname, (Last Name)First NameMiddle NameSuffix (i.e., Jr., Sr., II, III)Maiden Name, if applicableName(s) under which originally licensed in another state, if different from above (First, Middle, Last).2. Social SecurityNumber“Pursuant to Title 5, Chapter 76, of the Rhode Island General Laws, asamended, I attest that I have filed all applicable tax returns and paid alltaxes owed to the State of Rhode Island, and I understand that my SocialSecurity Number (SSN) will be transmitted to the Divison of Taxation toverify that no taxes are owed to the State.”U.S. Social Security Number3. GenderMaleFemale4. Date of BirthMonth5. HomeAddressIt is your responsibilityto notify the board of alladdress changes.No professionallicensee’s address(residence or business/employment) willbe posted on theDepartment’s Web site.Day1 9Year1st Line Address (Apartment/Suite/Room Number, etc.)2nd Line Address (Number and Street)CityStateCountry, If NOT U.S.Postal Code, If NOT U.S.Home PhoneZip CodeHome FaxEmail Address (Format for email address is Username@domain e.g. applicant@isp.com)6. BusinessAddress(ONLY if it isRELATED toyour license.)Name of Business/Work Location1st Line Address (Department/Suite/Room Number, etc.)Second Line Address (Number and Street)It is your responsibilityto notify the board of alladdress changes.This address willappear on the Department of Healthweb site.CityStateCountry, If NOT U.S.Postal Code, If NOT U.S.Business PhoneExtensionZip CodeBusiness FaxRhode Island Applied Behaviorial Analyst Licensing Board - Page 3

Applicant: Print your complete last name 7. PreferredMailingAddressPlease check ONEPlease use my Home Address as my preferred mailing addressPlease use my Business Address as my preferred mailing addressNOTE: The preferred mailing address that you indicate is the address that will be released for all requests for thatinformation.8. QualifyingEducationPlease list the nameand information aboutthe school that youattended thatqualifies you forthis license.Type of School (University, College, Technical School, etc.)Name of SchoolDate Graduated9. Other StateLicense(s)Please answer thequestion and liststate(s), if applicable10. LicensureList all states orcountries in whichyou are now, or everhave been licensedto practice yourprofession*.MonthYearDegree Received:YesHave you ever held, or do you currently hold, a license in another state?NoIf the answer to this question is “yes”, enter all other state licenses in Question 10 veInactiveActiveInactiveActiveInactive(*You must also request a License Verification from all states that are listed above)11. CriminalConvictionsRespond to thequestion at the topof the section, thenlist any criminalconviction(s) in thespace provided.Have you ever been convicted of a violation, plead Nolo Contendere, orentered a plea bargain to any federal, state or local statute, regulation, orordinance or are any formal charges pending?YesNoAbbreviation of State and Conviction1 (e.g. CA - Illegal Possession of a Controlled Substance):MonthYearIf necessary, youmay continue on aseparate 8½ x 11sheet of paper.Rhode Island Applied Behaviorial Analyst Licensing Board - Page 4

Applicant: Print your complete last name 12. DisciplinaryQuestionsCheck either Yesor No for eachquestion.1. Has any Health Professional license, certificate, registration, or permit youhold or have held, been disciplined or are any formal charges pending?YesNo2. Have you ever been denied a license, certificate, registration or permit inany state?YesNoNote: If you answer “Yes” to any question, you are required to furnish complete details, including date, place, reason anddisposition of the matter. You may use the space below or, if needed, on a separate sheet of paper.13. Affidavit ofApplicantComplete this sectionand sign.Make sure that youhave completed allcomponents accurately and completely.I, , being first duly sworn, depose and say that I am the personreferred to in the foregoing application and supporting documents.I have read carefully the questions in the foregoing application and have answered them completely, withoutreservations of any kind, and I declare under penalty of perjury that my answers and all statements made byme herein are true and correct. Should I furnish any false information in this application, I hereby agree thatsuch act shall constitute cause for denial, suspension or revocation of my license to practice as an AppliedBehavior Analyst/Assistant in the State of Rhode Island.I understand that this is a continuing application and that I have an affirmative duty to inform the Rhode IslandApplied Behavior Analyst Licensing Board of any change in the answers to these questions after this application and this affidavit is signed.Signature of ApplicantDate of Signature (MM/DD/YY)Rhode Island Applied Behaviorial Analyst Licensing Board - Page 5

Substitute forms are not acceptable, One (1) form is required for each state in which you hold, or have held a license.Copy this form as needed.Rhode Island Applied Behavior Analyst Licensing BoardRoom 104, 3 Capitol HillProvidence, RI 02908-5097(401) 222-2828INTERSTATE VERIFICATION FORM - OTHER STATE LICENSE(S) (One form for each state)I am applying for a license to practice as an Applied Behavior Analyst in the State of Rhode Island. The Rhode Island Applied Behavior Analyst Licensing Board requires that the following form be completed by the jurisdiction(s) in which I hold or have held a license. This constitutes authority for you torelease all information in your files, favorable or otherwise, directly to the Rhode Island Applied Behavior Analyst Licensing Board at he above address.Print/Type Full NameSignaturePrevious Names UsedSocial Security NumberDate19License NumberDate of BirthDate IssuedTHIS SECTION TO BE COMPLETED BY THE LICENSING AUTHORITYDirections for State Board: Please complete and return this form to the address above Please verify requirements met in your state:Applicant is BACB Certified?YesNoLicense Status:ActiveInactiveLapsedOriginal Date Issued:Expiration Date:Questions:1. Has this licensee ever been investigated by your Board?YesNo2. Has this licensee incurred any disciplinary proceedings in your state, or is any action pending?Yes No3. Has the applicant’s license ever been denied, surrendered, reprimanded, suspended, revoked or placedYes Noon probation?4. Do you know of any information that may discredit this person?Yes NoIf you answer “Yes” to questions 1-4, please provide a written explanation below, and attach a copy of all supporting documentation (e.g., Board order,complaint, etc.).Certification:Signature DateType or Print NamePlease AffixBoard Seal HereTitleFull Name and State of Licensing BoardPlease return directly to the Board at the above address. Thank you for your prompt cooperation.Rhode Island Applied Behaviorial Analyst Licensing Board - Page 6