NOVA SCOTIA BOARD OF EXAMINERS IN PSYCHOLOGY

Transcription

1 NOVA SCOTIA BOARD OF EXAMINERS IN PSYCHOLOGY APPLICATION FORM FOR REGISTRATION UNDER THE PSYCHOLOGISTS ACT (2000) c.32, OF NOVA SCOTIA NOTE: It is preferred that you complete the MS Word version of this application, but if not, please print legibly. Name: last first initial(s) Gender: M F date of birth: d m y Are you legally entitled to work in Canada? Home Address Telephone: fax: Work Address Telephone: fax: Please state the reason you are seeking registration in Nova Scotia Please state the name and address of your Nova Scotia employer(s): CONTACT INFORMATION FOR PUBLICATION IN THE DIRECTORY OF PSYCHOLOGISTS: Please Note: We do not recommend that you include your home address or contact information related to your home, i.e. home phone number, home , etc. in the Directory. Having accurate information however is helpful for others, i.e. clients or other professionals. Name: Address: Telephone: fax: I certify that the statements made by me in this application are complete and correct to the best of my knowledge and belief. Signature Date APPLICATION FEE $250.00: We encourage you to pay the application fee online by visiting the Application section of or you may do so by completing the below section. Cheque or Money Order enclosed: Visa MasterCard AMEX Paid Online Card Number: Expiry Date: Name on card Signature to authorize charge: Page 1 of 19

2 You are required to arrange for official transcripts or certifications of all relevant degrees to be sent by the educational institutions directly to the NSBEP office or if your degrees were acquired outside of the US or Canada, you must adhere to the requirements concerning transcripts and academic equivalency assessments outlined in the Board's document on Foreign Credentials. EDUCATIONAL BACKGROUND: Degree Awarded Dates of Attendance Date Awarded Educational Institution Department Title of Program Major Subject Minor Subject Bachelor's Degree Master's Degree Doctoral Degree Use additional space if necessary SUPERVISION, CONSULTATION & COLLEGIAL SUPPORT Candidates must have access to registered psychologists for collegial support, consultation and supervision relating to their work. Please state the name and credentials of your workplace supervisor. Please state the names of psychologists whom you can consult and receive collegial support from about workplace matters (in addition to your NSBEP Supervisor). CHILD ABUSE DECLARATION Part 1 (All applicants must complete Part 1) I certify that I have not been censured, reprimanded or found by a court to have abused children. Signature Page 2 of 19

3 Part 2 (Complete Part 2 if a separate Child Abuse Check is either unavailable in your jurisdiction or cannot be disclosed to the Nova Scotia Board of Examiners in Psychology, i.e., some jurisdictions may not intend for their registry checks to be used for the purpose of gaining registration outside of their jurisdiction.) I reside in a jurisdiction that, to the best of my knowledge, either does not maintain a Child Abuse Registry Check separate from a Criminal Record Check, or the agency maintaining this information cannot disclose such information to the Nova Scotia Board of Examiners in Psychology, or registry checks are not intended for the purpose of gaining registration outside of the jurisdiction. Signature EVALUATION OF FOUNDATIONAL KNOWLEDGE IN PSYCHOLOGY AS REQUIRED BY THE (AMENDED) MRA All applicants for initial registration with the Nova Scotia Board of Examiners in Psychology must be evaluated on their acquisition of a broad base of knowledge in the field of Psychology on which they can build the core competencies in Psychology within their areas of interest and expertise. Canadian Psychology Regulators agreed to evaluate applicants seeking entry to the profession on the following foundational knowledge areas by July 1, Applicants should identify at least one full credit psychology course or two half-credit psychology courses (graduate and/or undergraduate beyond introductory courses in each of the following four general areas of study in Psychology. For clarity, we are looking for at least 1 course that took place over the duration of two semesters or at least 2 courses that took place over the duration of one semester. Introductory courses (e.g. intro to ) are not acceptable. Please include both title and a brief course description for any courses listed below Graduates from a doctoral program in psychology that is accredited by the Canadian Psychological Association are deemed to meet the Foundational Knowledge criterion set out in the criteria for Degrees in Psychology Acceptable to the Nova Scotia Board of Examiners in Psychology. As such, graduates of a CPA Accredited Program are not required to complete the below section on Foundational Knowledge. 1. Knowledge in the biological bases of behaviour (for example, physiological psychology, comparative psychology, neurophysiology, sensation and perception, psychopharmacology) Page 3 of 19

4 2. Knowledge of the cognitive-affective bases of behaviour (for example, learning, cognition, motivation, emotion) 3. Knowledge of the social bases of behaviour (for example, social psychology, group processes, community psychology, environmental psychology, organizational and systems theory, cultural issues) 4. Knowledge of psychology of the individual (for example, personality theory, human development, psychopathology, individual differences) Page 4 of 19

5 CORE COMPETENCIES FOR ENTRY TO THE PROFESSION OF PSYCHOLOGY (AS REQUIRED BY THE MUTUAL RECOGNITION AGREEMENT (2001) OF THE REGULATORY BODIES FOR PROFESSIONAL PSYCHOLOGISTS IN CANADA) All applicants seeking entry to the profession of psychology are evaluated on the five core competencies. Canadian Psychology Regulators agreed to evaluate applicants seeking entry to the profession on the following core competencies by July 1, The Board s legislation requires registration decisions that are based on the graduate degree in psychology. As such, when looking at the core competencies, we are generally asking about formal coursework that is part of your graduate program(s) in psychology. Please briefly: a. identify relevant course work, practica, and internship experience for each of the following five competencies. b. include a description of each course, practicum and internship. (Use additional pages if necessary). 1. ASSESSMENT AND EVALUATION Definition - A competent professional psychologist draws on diverse methods of evaluation, determining which methods are best suited to the task at hand, rather than relying solely or primarily on formalized testing as an automatic response to situations requiring assessment. The appropriate subject of evaluation in many instances is not an individual person but a couple, family organization or system at some other level of organization. The skills required for assessment can and should be applied to many situations other than initial evaluation, including, for example, treatment outcome, program evaluation, and problems occurring in a broad spectrum of nonclinical settings. The primary purpose of psychological assessment is to provide an understanding that informs a practical plan of action. It may result in a diagnostic classification or in the identification of strengths or competencies. Knowledge: Should include: Knowledge of assessment methods, populations served, human development, diagnosis Skills: Should include: Experience in forming referral question, selecting methods, collecting and processing information, psychometric methods, forming hypotheses and making diagnoses, forming action plans, and writing reports Page 5 of 19

6 2. INTERVENTION Definition: The intervention competency is conceptualized as activities that promote, restore, sustain, and/or enhance positive functioning and a sense of well being in clients through preventative, developmental and/or remedial services. A broad comprehensive vision of the intervention competency should include explicitly theory as well as the following knowledge and skills. Knowledge: Should include: Knowledge of varied interventions with individuals and systems (e.g., families, organizations); of the relative efficacy of interventions to promote health and wellness; of the positive aspects of all major approaches, reflecting openness to varied viewpoints and methods; of when to make appropriate referrals and when to consult; and of cultural context and diversity, and implications for intervention Skills: Should include: Experience in selecting appropriate intervention methods; in analysing information, developing a conceptual framework, and communicating this to the client, as appropriate; in gathering information about the nature and severity of problems and forming hypotheses about factors contributing to the problem through qualitative and quantitative means; in learning to establish and maintain professional relationships with clients in all populations served; and in learning to establish and maintain appropriate interdisciplinary relationships with colleagues. 3. RESEARCH Definition: Professional psychological programs should include research training such that it will enable students to develop a basic understanding of and respect for the scientific underpinnings of the discipline, knowledge of methods to be good consumers of the products of scientific knowledge, and sufficient skills in the conduct of research to be able to develop and carry out projects in a professional or academic context. Knowledge: Should include: Knowledge of research methods and of the applications of scientific research; applied statistics and measurement theory; the logic of different models of scientific research (from laboratory experimentation to quasi-experimental and field research); and quantitative and qualitative research methods (including observation and interviewing), with respect to the nature of reliability and validity in the gathering and interpretation of data. Skills: Should include: Critical reasoning skills in interpreting and evaluating research procedures and findings; appropriate applications of various research approaches; and ability to write professional, scientific reports. Page 6 of 19

7 4. ETHICS AND STANDARDS Definition: Psychologists conduct themselves in an ethical manner consistent with the Canadian Code of Ethics for Psychologists. They conduct professional relationships within the context of the Code and Standards for the Profession. Knowledge: Should include: Knowledge of the ethical principles of the Canadian Code of Ethics and the ethical decision making process promoted with the Code, the Standards of Professional Conduct, the Standards for Providers of Psychological Services, and, as appropriate, other standards such as Standards for Psychological Tests and Measurements, Standards for Conducting Psychological Research, as well as relevant local Jurisprudence. Skills: Should include: Evidence of application of the ethical decision making process; pro-active identification of potential ethical dilemmas and application of the process for resolution of ethical dilemmas. 5. INTERPERSONAL RELATION SHIPS Definition: This basic competency forms part of all the other competencies. Psychologists normally do their work in the context of interpersonal relationships (parent-child, spouses, bossemployee, etc.) They must therefore be able to establish and maintain a constructive working alliance with their clients and possess adequate sensitivity to cultural issues. Knowledge: Should include: (i) Knowledge of theories and empirical data on the professional relationship, such as interpersonal, power relationships, therapeutic alliance, interface with social psychology, and fluctuations of the therapeutic/professional relationship as a function of the intervention setting (ii) Knowledge of self, such as motivation, resources, values, personal biases and factors that may influence the professional relationship (e.g., boundary issues) (iii) Knowledge of others, such as macro-environment in which the person functions (e.g., work, national norms) and micro-environment (e.g., personal differences, family, gender differences) Skills: Should include: Evidence of effective communication, and evidence of establishment and maintenance of rapport, and of trust and respect in professional relationships. Page 7 of 19

8 BACKGROUND QUESTIONNAIRE Please answer the following questions by circling Yes or No and filling in the blank if appropriate. If the answer to any of the questions is yes, then please provide the details on a separate sheet. Have you ever: Had an application for registration, certification or licensing as a psychologist or in another profession rejected? Been found in violation of ethical principles by an ethics or professional practices board in relation to psychology or another profession? Voluntarily surrendered a professional credential in response to an ethics charge in relation to psychology or another profession? Received disciplinary action from an ethics or professional practice board in relation to psychology or another profession? Been notified of any pending disciplinary action from an ethics or professional practice board in relation to psychology or another profession? Had a professional credential revoked, suspended or limited by an ethics or professional practices board in relation to psychology or another profession? Been convicted of, or pleaded guilty to a summary conviction offense or an indictable offense, other than a minor traffic offense, in a federal or provincial court? Received formal disciplinary action by an employer or supervisor based wholly or in part on ethical issues? Held or do you currently hold registration or a license in another profession other than psychology? If yes to above, Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No What profession? What is the current status of said registration? I understand that the Board may request any further information it may consider necessary in order to evaluate this application. Signature Date Page 8 of 19

9 DECLARATION OF PSYCHOLOGICAL PRACTICE For the purposes of registration, applicants are asked to declare their area of intended practice in psychology via the Psychological Practice Profile. Please note the following: When completing all areas of this form, please bear in mind that the Board wants to know what you are either doing presently or what you are planning to do in the very near future. We are neither asking about activities in the more distant future nor asking for you to declare all that you could do. However, in future, other activities and populations could be added to one's profile, provided one has relevant training and experience. With applicants to the profession, the current policy of the Board is that the area of practice being declared must be identified by the program of study. This generally means that the applied area of practice declared by an applicant must be consistent with the area stated on the transcript, e.g. Clinical Psychology, Counselling Psychology, School Psychology, etc.; or the area should be consistent with the title of the program identified by the university or through programmatic accreditation of the program (e.g. CPA Accredited Program in Counselling Psychology). However, given that there are fewer programs specifically titled as Forensic Psychology, the Board will look at the educational preparation of the applicant beyond the transcript or programmatic accreditation, to see whether one s program of study and training and experience has offered adequate concentration in Forensic Psychology and to ensure that appropriate supervision related to Forensic Psychology will be available to the candidate. In addition to one s declared area of applied practice, one may be engaging in formal research or teaching psychology courses. As such, the Board has included the areas of Formal Research and Academic Psychology. Within the category of Formal Research, NSBEP is interested in capturing the time you spend completing formal research work (versus the time spent developing and maintaining competence). Time spent developing and maintaining competence, etc., should be captured but assigned to the corresponding activity category. For example, time spent reviewing literature on interventions would be entered in the Intervention/Treatment category. The Board has also included a category for Administration since a number of psychologists hold such positions. Within the category of Administration, NSBEP is not referring to the completion of general administrative work (such as paperwork), rather we are referring to psychologists who hold a position in which they manage a psychological service unit. The Board s defined areas of practice are available via the NSBEP document entitled Appropriate Practice Areas which can be accessed via this link: Your professional referees are asked to comment on your completed declaration. Page 9 of 19

10 Instructions for completion Part A asks about your employment status, practice setting(s), and language(s)*. Please indicate whether your employment status is full or part time. (Those working part time please indicate how many hours per week.) Then check the applicable practice setting(s) in which you are employed and identify the applicable languages in which you are comfortable providing services. *Information about language(s) of service is helpful for the public, e.g. NSBEP Directory of Psychologists (listing by language), Directory of French Speaking Health Care Providers. Part B of the Psychological Practice Profile asks about your area(s) of your psychological practice. Please check the area(s) of your psychological practice and estimate the percentage of time you spend working in each area. For instance, if you spend four days per week engaged in clinical work and one day per week doing research, you would check #1, Clinical, and #5, Research. You would then write in 80% for Clinical and 20% for Research. The total percentage of time should add up to 100%. If you hold competency in an area but are not currently practicing in this area, you can identify this by placing a check mark and zero in this box. Part C of the Psychological Practice Profile asks you to indicate the activities and services you provide within the areas of practice indicated in Part B. For instance, if your clinical work involves Consultation, Assessment/Evaluation, and Intervention/Treatment with Adults you would enter #1 in the appropriate boxes for Adults. Likewise, if your research was with adults, you would enter #5 in the box corresponding to Research and Adults. Information about practice areas and populations can be very helpful for the public and mental health professionals when making referrals (e.g. Directory of Psychologists). Some Clarifications Within the category of Consultation, NSBEP is interested in the time spent completing any work done on behalf or at the request of another health professional. For instance, a GP might be concerned that one of his patients is depressed, and asks for your opinion. The time spent talking to the GP to clarify the concerns and time providing feedback after seeing the patient would be entered under Consultation. With the category of Assessment, NSBEP is interested in the time you spend completing both psychometric assessment and non-psychometric assessment function, i.e. in order to provide an understanding which informs a practical plan of action. Some individuals may confuse clerical work with Administration. Time spent completing any clerical work should not be assigned to the category of Administration (as previously noted we are referring to managing a psychological service unit when using the term Administration). Rather, such work should be assigned to the corresponding activity category. For instance, if you are completing clerical paperwork in relation to an assessments you have completed, this should be entered in the Assessment / Evaluation category. Similarly, if your paperwork is in relation to an intervention then it should be captured under the Intervention / Treatment category. The categories of Formal Research & Academic & Administration are included in both Sections A & C of the Psychological Practice Profile so that the corresponding populations can be tracked for these areas. Page 10 of 19

11 PSYCHOLOGICAL PRACTICE PROFILE A. Please affirm your overall employment status, all practice setting, and language(s). Overall I will be employed: Full-time Part-time Not currently working If employed part-time, how many hours per week will you average?: In the area below, please check the applicable practice setting(s) in which you will be employed. Private Practice Community Agency Hospital School Counselling Centre University/College Government Other You are comfortable to provide services in: English, French, other language(s) B. In the area below, check the applicable area(s) of your intended psychological practice 1 and indicate the percentage of your time spent working in the area(s). 1. Clinical Psychology 3. School Psychology 2. Counselling Psychology 4. Forensic/ Correctional Psychology 5. Formal Research 6. Academic (teaching psychology) 7. Industrial / Organizational Psychology 9. Administration 8. Clinical Neuropsychology C. Once you have indicated your area(s) of practice, use the corresponding numbers to identify in the below table the activities and services you will provide and the clients to whom you will provide these services. Clients Administration Consultation Assessment/ Evaluation Intervention/ Treatment Formal Research Academic Infants Children Adolescents Adults Elderly Families Couples Organizations Print Name Date Applicant s Signature 1 The Board recognizes that subspecialty areas of practice are evolving (e.g. Health Psychology, etc.) but such areas should correspond with the broader practice areas (e.g. Clinical Psychology). Page 11 of 19

12 RELEVANT PSYCHOLOGY POSITIONS HISTORY (IF APPLICABLE) Fill in this section only in relation to psychology positions. We would consider such a position to either have psychology or psychological in the title or be primarily psychological in content and involve the practice of psychology in the core competency areas. On the other hand, experience from practica or internships should be noted in the appropriate section of the application form; and other related work experience (but not strictly a psychology position) should be listed on your CV. Present employment: Hiring date: Organization/Institution Address of Organization Name of Supervisor and profession: name profession Address of your supervisor if different from above: Your position Service you offer If part-time, state average number of hours per month Previous relevant employment (in the field of Psychology): Hiring date to Organization Address of organization Name of supervisor and profession Address of your supervisor if different from above: Your position Services you offered If part-time, state average number of hours per month (Attach additional pages if necessary) Page 12 of 19

13 CREDENTIALS FROM OTHER REGULATORY BOARDS IN PSYCHOLOGY (IF APPLICABLE) Title of credential Name of agency/ board Address of agency/board Original date of Certificate/License Certificate/License number Specialty area (if designated): Is the Certificate/License current? Yes No Note: In addition to the above information, verification of your good standing must be sent directly to the Board office from the granting agency. Page 13 of 19

14 VERIFICATION OF PRACTICA & INTERNSHIP Applicant s name: This form is to be completed by a person authorized to do so by the university and sent directly to the NSBEP. Documentation of Internship (I) Practicum (P) Applicants are evaluated in terms of knowledge and skills acquired through a graduate program in psychology. In addition to coursework in psychology the applicant is expected, as part of the graduate program, to have completed some practice in psychology. Please complete the following information for each placement/practice program undertaken by the applicant to complete requirements for the graduate program. (Use additional pages if necessary). Course # and Name This course was an I P Date placement began Date placement completed Number of hours completed during placement Name of placement setting Primary placement supervisor Professional qualifications of supervisor Course # and Name This course was an I P Date placement began Date placement completed Number of hours completed during placement Name of placement setting Primary placement supervisor Professional qualifications of supervisor Course # and Name This course was an I P Date placement began Date placement completed Number of hours completed during placement Name of placement setting Primary placement supervisor Professional qualifications of supervisor I certify that the above placements were completed as part of the applicant s graduate program requirements. Signature Date Name Position Title University Address Phone Send to: The Nova Scotia Board of Examiners in Psychology 5991 Spring Garden Road, Suite 455 Halifax, NS B3H 1Y6 Phone: Fax: Page 14 of 19

15 REFERENCES: List the name, position, address, and phone number of three referees who are well acquainted with you and your professional work. Two of these referees must be registered or licensed psychologists. 1. Name: Position: Address Phone number 2. Name: Position: Address Phone number 3. Name: Position: Address Phone number Make 4 additional copies of your completed Psychological Practice Profile. The original must be sent to the Nova Scotia Board of Examiners with your application. Give a completed copy of the Psychological Practice Profile (along with a copy of the Reference Form below) to each of the three referees listed above who will be asked to comment upon your competence to engage in your intended area of psychological practice. The Nova Scotia Board of Examiners in Psychology 5991 Spring Garden Road, Suite 455 Halifax, NS B3H 1Y6 Phone: Fax: Page 15 of 19

16 REFERENCE FORM APPLICANT S NAME: The above named person is applying for registration as a Psychologist (Candidate Register), under the Psychologists Act (2000) of the Province of Nova Scotia. Applications are not evaluated until all references have been received. Your co-operation in prompt completion and return of this reference form will be very much appreciated. Please complete the following: Your name (please print) Your current position/title Your organization/institution Your signature Date I am currently registered/certified/licensed in the Province/State of Registration # Effective dates: from to I am a member of: APNS (Class), CPA (Class), APA (Class) Membership in other psychological associations: I have known the applicant for year(s) from to During this time my relationship to her/him has been that of: professor \ supervisor department head \ co-worker Other (please specify) His/her responsibilities were: Percent of time Percent of time Her/his position(s) or job title(s) in the organization(s) were: Position Organization Percent of time Reference Form continues on next page... Page 16 of 19

17 Consider the principal relationship you had to the applicant. Please indicate on the following scales the applicant s competence (relative to others you have known at a similar level of training and experience), with the very best approaching 100. Unable to Judge Technical competence Specialized knowledge relevant to intended area of psychological practice Ethical behaviour Emotional maturity for professional role Capacity for professional growth and development Overall suitability for professional psychology practice The applicant has provided you with a copy of his/her Psychological Practice Profile Form. Please comment below on the appropriateness of the applicant's identified area(s) of Psychological services provision. Include comments on your reservations, and mention those areas where you cannot offer an informed comment. Use additional pages, if needed. Send to: The Nova Scotia Board of Examiners in Psychology Spring Garden Road Halifax, NS B3H 1Y6 Phone: Fax: Page 17 of 19

18 SUPERVISOR'S CONSENT FORM I,, am applying for registration under the Psychologists Act (2000) of Nova Scotia. I am required by the Nova Scotia Board of Examiners in Psychology (NSBEP) to be supervised while I am on the Candidate Register prior to transfer to the Register of Psychologists. My supervisor must be a registered psychologist qualified in my area(s) of practice and acceptable to the Board. Supervision requirements include a minimum of 2 hours monthly of face-to-face individual contact to address the professional goals of the candidate. I. PROPOSED SUPERVISOR Name and address: Highest degree: Area(s) of practice & expertise Business phone #: Is your registration as a psychologist in Nova Scotia current: yes no NSBEP requires curriculum vitae from all proposed supervisors. If you have been a NSBEP Supervisor in the last five years (in which case your CV would be on file) you are not required to resubmit your CV. II. PAYMENT FOR SUPERVISION There is no rule prohibiting payment of supervisors, but it is not considered typical practice. Will a fee be charged for supervision? Yes No If yes, indicate amount per hour: $ III. CONFLICT OF INTEREST To avoid any conflict of interest or perceived conflict of interest, the supervisor(s) chosen should not have a significant personal or financial relationship with the candidate. Candidates are not permitted to have their employer or workplace supervisor as their NSBEP supervisor. I,, agree to supervise for years. We have discussed the conflict of interest clause and agree that we will immediately inform the Board of personal or financial relationships that constitute conflict of interest or give the appearance of such. Applicant s Signature Proposed Supervisor s Signature Date Supervisors List (This option is to be completed by the Proposed Supervisor) Often applicants for registration and others can have a difficult time securing a supervisor. Please indicate whether you would like your name added to a list that can be shared with other applicants/registrants seeking a supervisor. YES please add me to a list that can be shared with applicants/registrant seeking a supervisor. NO please do not add me to the list at this time. Page 18 of 19

19 APPLICANT CHECKLIST Please forward all documentation to: The Nova Scotia Board of Examiners in Psychology Suite Spring Garden Road Halifax, NS B3H 1Y6 Have you? 1. Completed payment of application fee online or included payment with your completed application form? 2. Included a copy of your curriculum vitae? 3. Included a copy of your official photo identification? (e.g. Driver's license, Passport) 4. Included the completed Supervisor s Consent Form? (Must also include Supervisor s CV if he/she has not been a NSBEP Supervisor in the last 5 years) 5. Arranged to have your transcripts (undergraduate and graduate) sent directly to NSBEP and if your degree(s) are from outside the US or Canada, have you adhered to the requirements for transcripts and academic equivalency assessments noted in the Board's document on Foreign Credentials? 6. Provided the Verification of Practica & Internship Form to a person authorized by the university to complete it along with instructions to send the completed form directly to NSBEP? 7. Either ordered your Criminal Record Check using the suggested online process or requested it from police (which you will then need to send to NSBEP)? Please note: if your criminal record check included a vulnerable sector check or screening, it does not replace the need for you to follow the below requirements concerning Child Abuse. 8. Completed Part 1 of the Child Abuse Declaration? 9. Either ordered your Child Abuse Check (which you will then need to send to NSBEP), or if applicable, completed Part 2 of the Child Abuse Declaration? 10. Provided each of your references with: a. copy of your completed Psychological Practice Profile b. copy of the Reference Form for their completion along with instructions to send the completed form directly to NSBEP? 11. If you hold any registration with another psychology regulatory body, have you requested that they send verification of your good standing? Good standing refers to: a. no past or outstanding complaints; b. no conditions or restrictions on your registration. 12. Provided an address? We generally communicate the results of an approved application by . Rev. September 2014 Page 19 of 19