20:60:05:05Application 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.