To apply for a credential to practice as a licensee under
the Act, an individual must submit a complete application to the Department. A
complete application includes all required documentation, the required fee, and
a written application. The applicant may obtain an application from the
Department or construct an application that must contain the following
information:
1.
Written
Application: An individual may apply for 1 or more licenses under
a single application. The Department issues licenses to individuals for any
category or combination of categories for which they have passed any required
examination(s) and otherwise meet the requirements of the Act and 178 NAC 10.
a. Personal Information:
(1) The legal name of the applicant, maiden
name (if applicable), and any other names by which the applicant is
known;
(2) Date of birth (month,
day, and year);
(3) Place of birth
(city and state or country if not born in the United States);
(4) Mailing address (street, rural route, or
post office address; and city, state, and zip code, or country
information);
(5) The applicant's:
(a) Social Security Number (SSN);
or
(b) Alien Registration Number
("A#"); or
(c) Form I-94
(Arrival-Departure Record) number).
Certain applicants may have both a SSN and an A# or I-94
number, and if so, must report both.
(6) The applicant's telephone number
including area code;
(7) The
applicant's e-mail address (optional);
(8) The applicant's fax number
(optional);
(9) Citizenship: The
applicant must state that s/he is one of the following:
(a) A citizen of the United States;
(b) An alien lawfully admitted into the
United States for permanent residence under the Immigration and Nationality Act
(INA) and who is eligible for a credential under the Uniform Credentialing Act;
or
(c) A non-immigrant whose visa
for entry, or application for visa for entry, is related to employment as a
credential holder in the United States;
b.
Practice Before
Application: The applicant must state:
(1) That s/he has not practiced as a licensee
under the Act in Nebraska before submitting the application; or
(2) If s/he has practiced as a licensee under
the Act in Nebraska before submitting the application, the actual number of
days practiced in Nebraska before submitting the application for a credential
and the name and location of practice;
c. The type of license desired;
d. The name, address and telephone number of
the business with which the applicant is/will be engaged;
e. All addresses and phone numbers of each
business location;
f. The nature of
the business;
g. The person's
affiliation with the business;
h.
The name of all partners in a partnership and the business address and
telephone number of each partner;
i. If a corporation, the officers and
directors of that corporation and the address and telephone number for each
office of that corporation within the state.
j. If applying for licensure as a water well
and/or pump installation contractor, proof of public liability and property
damage insurance in the amount of at least $100,000 from the insurance
company(ies);
k. If the applicant
is licensed/certified in any other state or jurisdiction, and whether or not
disciplinary action has been taken against the license/certificate;
l. Which exam(s) s/he needs to take: the
Nebraska exam, the water well monitoring technician exam, the natural resources
ground water technician exam, the pump installation exam, and/or the general
drilling exam.
m. Persons
requesting a hardship exemption for licensure must indicate the reasons for the
request;
n. Persons requesting
special arrangements for administering the exam must list the reasons for the
request and the special arrangements sought, and
o.
Attestation: The
applicant must attest that:
(1) S/he has read
the application or has had the application read to him/her;
(2) All statements on the application are
true and complete;
(3) S/he is of
good character
(4) S/he has not
committed any act that would be grounds for denial under 178 NAC
10-009. or if an act(s) was
committed, provide an explanation of all such acts; and
(5) For the purpose of complying with
Neb. Rev. Stat.
§§
4-108
to
4-114,
s/he is a citizen of the United States or a qualified alien under the federal
Immigration and Nationality Act. The applicant must provide his/her immigration
status and alien number, and agree to provide a copy of his/her United States
Citizenship and Immigration Services (USCIS) documentation upon
request.
2.
Documentation: The applicant must submit the following
documentation with the application:
a.
Evidence of age, such as:
(1) Driver's
license;
(2) Birth
certificate;
(3) Marriage license
that provides date of birth;
(4)
Transcript that provides date of birth;
(5) U.S. State identification card;
(6) Military identification; or
(7) Other similar documentation;
b. Evidence of good character,
including:
(1)
Other Credential
Information: If the applicant holds a credential to provide health
services, health-related services, or environmental services in Nebraska or in
another jurisdiction, the applicant must submit the state, credential number,
type of credential, date issued, and expiration date of each credential where
the applicant has been or is currently credentialed. The applicant must have
the licensing agency submit to the Department a certification of his/her
credential;
(2)
Disciplinary Action: A list of any disciplinary
actions taken against the applicant's credential and a copy of the disciplinary
action(s), including charges and disposition;
(3)
Denial: If the
applicant was denied a credential or denied the right to take an examination,
an explanation of the basis for the denial;
(4)
Conviction
Information: If the applicant has been convicted of a felony or
misdemeanor, the applicant must submit to the Department:
(a) A list of any misdemeanor or felony
convictions;
(b) A copy of the
court record, which includes charges and disposition;
(c) Explanation from the applicant of the
events leading to the conviction (what, when, where, why) and a summary of
actions the applicant has taken to address behaviors/actions related to the
conviction;
(d) All
addiction/mental health evaluations and proof of treatment, if the conviction
involved a drug and/or alcohol related offense and if treatment was obtained
and/or required;
(e) A letter from
the probation officer addressing probationary conditions and current status, if
the applicant is currently on probation; and
(f) Any other information as requested by the
Board/Department;
c. Evidence that the applicant is:
(1) A citizen;
(2) An alien lawfully admitted into the
United States for permanent residence under the Immigration and Nationality Act
(INA) who is eligible for a credential under the Uniform Credentialing Act;
or
(3) A non-immigrant whose visa
for entry, or application for visa for entry, is related to employment as a
credential holder in the United States; d. Evidence of citizenship, lawful
permanent residence, and/or immigration status may include a copy of:
(1) A U.S. Passport (unexpired or
expired);
(2) A birth certificate
issued by a state, county, municipal authority or outlying possession of the
United States bearing an official seal;
(3) An American Indian Card
(I-872);
(4) A Certificate of
Naturalization (N-550 or N-570);
(5) A Certificate of Citizenship (N-560 or
N-561);
(6) Certification of Report
of Birth (DS-1350);
(7) A Consular
Report of Birth Abroad of a Citizen of the United States of America
(FS-240);
(8) Certification of
Birth Abroad (FS-545 or DS-1350);
(9) A United States Citizen Identification
Card (I-197 or I-179);
(10) A
Northern Mariana Card (I-873);
(11)
An Alien Registration Receipt Card (Form I-551, otherwise known as a "Green
Card");
(12) An unexpired foreign
passport with an unexpired Temporary I-551 stamp bearing the same name as the
passport;
(13) A document showing
an Alien Registration Number ("A#") with visa status; or
(14) A Form I-94 (Arrival-Departure Record)
with visa status;
(15) A request
for special accommodations, if special testing accommodations are needed by the
applicant;
(16) Any other
documentation as requested by the Board/Department; and
