Fill and Sign the Intake Form Reflexology

All information Requested on this Form Must be Typewritten or Printed ARKANSAS STATE BOARD OF REGISTRATION FOR FORESTERS 3821 W. Roosevelt Rd. – Little Rock, AR 72204 APPLICATION FOR LICENSE AS REGISTERED FORESTER 1. General Information Date ______________________ Name in full _____________________________________ Social Security # _____________________ Mailing Address _______________________________ City ________________ State ____ Zip _____ Residential Address ____________________________ City ________________ State ____ Zip ______ Present Position _______________________________ Firm __________________________________ Business Address ______________________________ City ________________ State ____ Zip ______ Telephone: Home _________________ Business ___________________ Fax _____________________ Birthplace ______________________________ Date of Birth _______________ U.S. Citizen Y/N ___ E-mail address _______________________________________________________________________ (Give names and addresses of five References, not relatives; at least three of whom are registered foresters having knowledge of your character and professional reputation. Do not use Board Members as references.) 1. 2. 3. 4. 5. Name Address Position/Firm ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 2. Registration in other states State Board of Registration first registered with ____________________________________________ Date of registration ___________________________ License number __________________________ Licensed by examination? Y/N ___ If not, how? ___________________________________________ Is license now in force? Y/N _____ If not, why? ___________________________________________ Has license ever been revoked? Y/N ___ If so, why? ________________________________________ Other states in which registered _________________________________________________________ 3. Technical and/or Professional Examinations (Give information on examinations satisfactorily passed in connection with forestry registration, civil service, merit system, etc.) Conducted by Location 4. Date Rating Information for applicants All applicants must submit this form along with a $10 application fee to the Arkansas Board of Registration for Foresters at the above address. The application fee is not refundable. The Board will schedule examination dates and notify qualifying applicants of the date and place. Upon successful completion of all requirements for becoming an Arkansas Registered Forester, the Board requires an additional fee $30 for registration. The Board will issue a license to those applicants who meet the qualification stated in ACA §17-31-301 through 310. 5. Membership in Societies, Associations, or Institutes (Professional or Scientific) Name of Organization Executive Headquarters 6. Membership Class Date Joined Education (State in chronological order the name and location of each school, college, university, or technical school attended, the time spent at each, and if graduated, the year of graduation with degree granted.) Name and location of Institution Years (from-to) Date Graduated 7. Major Degree Professional Experience (Applicants must fill out all columns. Use additional sheet if necessary.) Date From Title of position held, name and address of employer, and character of each engagement. Be specific as to responsible work preformed. To Supervisor or knowledgeable associate Indicate fields or phases of forestry in which you are most proficient, such as silviculture, finance, appraisals, mensuration, fire control, administration, reforestation, utilization, research, teaching, other (specify). 8. Code of Ethics The applicant agrees to conform to the following rules of professional conduct: 1. The applicant will advertise only in a dignified manner, setting forth in truthful and factual statements the services he/she is prepared to render for his/her respective clients and for the public. 2. The applicant will strive for correct and increasing knowledge of forestry and dissemination of this knowledge, and will discourage and condemn the spreading of untrue, unfair, and exaggerated statements concerning forestry. 3. When serving as an expert witness on forestry matters, in a public or private fact finding proceeding, he/she will base his/her testimony on adequate knowledge of the subject matter, and render his/her opinion on his/her own honest convictions. 4. The applicant will refrain from expressing publicly an opinion on a technical subject unless he/she is informed as to the facts thereto, and will not distort or withhold data of a substantial or other nature for the purpose of substantiating a point of view. 5. The applicant will not voluntarily disclose information concerning the business affairs of his employers, principals or clients, which they desire to keep confidential, unless express permission is first obtained. 6. The applicant will not, without the full knowledge and consent of his client or employer, have an interest in any business, which may influence his judgment in regard to the work for which he is engaged. 7. The applicant will not, for the same service, accept compensation of any kind, other than from his client, principal, or employer, without full disclosure, knowledge, and consent of all parties concerned. 8. The applicant will engage, or advise his client or employer to engage, other experts and specialist in forestry and related fields whenever the client’s or employer’s interest would be best served by such actions, and will cooperate freely with them in their work. 9. The applicant will aid in safeguarding against the registration of persons unqualified because of lack of good moral character or of adequate training. 10.If the applicant has substantial and convincing evidence of unprofessional conduct a registered forester, he/she will present the information to the State Board of Registration for Foresters. 9. Affidavit STATE OF ___________________________ } } ss. County of ___________________________ } _________________________________________________, being first duly sworn, deposes and says: I, the Applicant named in this application, have read the contents hereof, and to the best of my knowledge and belief the foregoing statements are true in substance and effect and are made in good faith and I hereby subscribe to the agree to conform with the Code of Ethics set forth in section 8 above. ______________________________________ Signature of Applicant Subscribed and sworn to before me this ______ day of _______________, 2______ ______________________________________ Signature of Notary Public My commission expires ______________________ 10. Record of Board (This space for use only be the Board.) Date application received _______________ Amount paid __________ Date reviewed __________ Date(s) examination given ________, _________, _________ Ratings _______, _______, _______ Qualified under ACA § 17-31-302 (1) __, (2) __, (3) __, (4) __, (5) __ Action of the Board _____________________________ License No. _____ Date issued ________ Endorsement of Board _________________________ ____________________________________________ (seal) ____________________________________________