OSDH Form 1058 "Application Form" - Oklahoma

What Is ODH Form 1058?

This is a legal form that was released by the Oklahoma State Department of Health - a government authority operating within Oklahoma. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on October 1, 2021;
  • The latest edition provided by the Oklahoma State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ODH Form 1058 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 1058 "Application Form" - Oklahoma

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Oklahoma State Department of Health
Consumer Health Service
P
ROTECTIVE
Occupational Licensing
H
Licensed Genetic Counselors
EALTH
Mail: PO Box 268815, Oklahoma City, OK 73126-8815
Physical: 123 Robert S Kerr Ave, Oklahoma City, OK 73102
S
ERVICES
Phone: (405) 426-8250 // Fax: (405) 900-7557
Website:
http://chs.health.ok.gov
APPLICATION FORM
Please check the license you are applying for:
Licensed Genetic Counselor (LGC)
Licensed Genetic Counselor – Temporary
Please type or print legibly:
Applicant's Name:
Social Security Number:
Birth date:
Sex:
M
F
Mailing Address:
City, State, Zip:
Area code & Telephone:
E-mail Address:
Current Place of Employment:
Telephone at Current Place of Employment:
Education: College/University granting the qualifying degree
(Please print out the full name of the school - do not abbreviate or use initials)
Name of Institution:
Location:
Degree Received:
Date of Graduation:
Specialty:
Name(s) on transcript(s) if different from that listed above:
Other Credentials: If you possess professional licenses or certificates issued by Oklahoma or other states, give
license or certificate titles, numbers, states issuing, and expiration dates:
Professional Misconduct:
Have you ever had your professional membership, registration, certificate, or license suspended, revoked,
restricted, or denied or has any other disciplinary action been taken against you by any professional
organization, federal or state regulatory body or foreign jurisdiction, or are you presently under investigation by
any regulatory body, to the best of your knowledge?
Yes
No
Oklahoma State Department of Health
ODH Form #1058
(Rev. 10/21)
Protective Health Services
PAGE 1 OF 2
Oklahoma State Department of Health
Consumer Health Service
P
ROTECTIVE
Occupational Licensing
H
Licensed Genetic Counselors
EALTH
Mail: PO Box 268815, Oklahoma City, OK 73126-8815
Physical: 123 Robert S Kerr Ave, Oklahoma City, OK 73102
S
ERVICES
Phone: (405) 426-8250 // Fax: (405) 900-7557
Website:
http://chs.health.ok.gov
APPLICATION FORM
Please check the license you are applying for:
Licensed Genetic Counselor (LGC)
Licensed Genetic Counselor – Temporary
Please type or print legibly:
Applicant's Name:
Social Security Number:
Birth date:
Sex:
M
F
Mailing Address:
City, State, Zip:
Area code & Telephone:
E-mail Address:
Current Place of Employment:
Telephone at Current Place of Employment:
Education: College/University granting the qualifying degree
(Please print out the full name of the school - do not abbreviate or use initials)
Name of Institution:
Location:
Degree Received:
Date of Graduation:
Specialty:
Name(s) on transcript(s) if different from that listed above:
Other Credentials: If you possess professional licenses or certificates issued by Oklahoma or other states, give
license or certificate titles, numbers, states issuing, and expiration dates:
Professional Misconduct:
Have you ever had your professional membership, registration, certificate, or license suspended, revoked,
restricted, or denied or has any other disciplinary action been taken against you by any professional
organization, federal or state regulatory body or foreign jurisdiction, or are you presently under investigation by
any regulatory body, to the best of your knowledge?
Yes
No
Oklahoma State Department of Health
ODH Form #1058
(Rev. 10/21)
Protective Health Services
PAGE 1 OF 2
Have you ever had professional privileges in a hospital, HMO, etc., suspended or restricted or has any other disciplinary
action been taken against you on grounds of unprofessional conduct, incompetence, negligence or unsafe practice?
Yes
No
Has any claim been made against you in a criminal or a civil suit or any other forum in the past ten years which clearly
alleges unethical behavior on your part, including but not limited to the following examples: sexual intimacy with a
patient, a dual relationship with a patient, violation of confidentiality, or any other offense which might relate to your
professional practice?
Yes
No
Have you ever voluntarily given up privileges, registration, certificate or license to practice your profession or agreed to
restrict your practice?
Yes
No
If you answered "Yes" to any of the four preceding questions, provide detailed information on a separate piece of paper.
Have you ever been convicted of a felony or a misdemeanor?
Yes
No
If your answer to the immediately preceding question is “Yes,” please provide the following information:
Date of conviction:
Where convicted:
Charge:
If the conviction was set aside, give the date and provide detailed information on a separate piece of paper.
References:
Separate documents in your application packet call for recommendations from third parties. Three documents must be
submitted. The rater must be a professional who is familiar with your personal character and professional skills. Do
not request a person to act as a reference who is an employee of the Department of Health, a member of the Infant and
Children’s Health Advisory Council, or a member of your family.
Proposed Professional Practice:
Please describe how you plan to use your license including: 1.) type of professional setting (hospital, clinic, etc.)
2.) client population 3.) client age range 4.) type of practice (private not for profit, private for profit).
PLEASE READ CAREFULLY
I understand that the Oklahoma Open Records Act requires that all records contained in my licensing file, with the
exception of my university transcripts and any documents associated with an on-going investigation of my professional
conduct, are available for public scrutiny and photocopying. I hereby grant permission to the Department to seek any
information or references deemed fit in securing my credentials pertinent to this application.
I further agree that if issued a license, upon the revocation of the license, I shall return said license. The information that I
have provided in this application is truthful. I understand the giving the Department false information of any kind may
result in the voiding of this application and possible disciplinary action.
I have read the Act and Regulations relevant to the license for which I am applying, understand them, and agree to
abide by them.
Date
Signature of Applicant
Oklahoma State Department of Health
ODH Form #1058
(Rev. 10/21)
Protective Health Services
PAGE 2 OF 2
Page of 2