APPENDIX A
FORM

Please print or type all information, except where a Signature is designated.

I, ____________________________________, do hereby attest under penalty of perjury that I meet all of the below-listed conditions of eligibility as a military spouse relocated to the State of Alabama:

➢ I am the spouse of an active duty reserve or transitioning member of the United States Armed Forces, including the National Guard, or a surviving spouse of a service member who, at the time of his or her death, was serving on active duty and who is relocated to and stationed in the State of Alabama under official military orders. A transitioning service member is a member of the United Stated Armed Forces, including the National Guard, on active duty status or on separation leave who is within 24 months of retirement.                                       Place initials here ______

➢ I hold an active license to practice athletic training in the State of ___________________ and left employment in said state to accompany my spouse to the State of Alabama.                                           Place initials here ______

➢ My current license is in good standing.                   Place initials here ______

➢ No disciplinary action has ever been taken or, to my knowledge, is pending, against my license.                                                 Place initials here ______

➢ I have not committed or participated in an act that would constitute grounds for refusal, suspension, or revocation of a professional license.
Place initials here ______

Attached hereto are a copy of my military identification card and a copy of my spouse’s transfer orders. I understand that I may need to provide the Alabama Board of Athletic Trainers with additional documents in support of my application.
Place initials here ______

Upon determination of my eligibility as a military spouse, sufficient documentation of my spousal relationship, and my spouses transfer orders, I hereby request that the licensure fee of $175 be waived.                            Place initials here ______

As indicated by my initials contained in the body of this form, I have reviewed the details of each area of eligibility and documentation requirements and state under penalty of perjury that the information contained in this application is true and correct to the best of my knowledge.

_________________________________________             ________________________________
Signature                                             Date
_________________________________________
Printed Name

Author: Leah Taylor, Executive Secretary

Statutory Authority: Code of Ala. 1975, §§34-40-5(1), 34-40-3(3)(g).

History: New Rule: Published December 31, 2019; effective February 14, 2020.