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Interpreter Licensure Application

Boards & Commissions > Boards > Interpreters for the Deaf, Advisory Board > Interpreter Licensure Application

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- Interpreters for the Deaf, Advisory Board
  - Interpreter Licensure Application
  - Provisional Licensure Application

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Application and Renewal Form for Interpreter Licensure

Advisory Board for Interpreters between Hearing Individuals and Individuals who are Deaf, Deafblind, Hard of Hearing or Oral Deaf Application and Renewal for Licensure. Please allow up to 3 weeks for processing. If you are viewing this form from a mobile device, you may have to switch your browser to “Desktop Mode/View” to submit the form.

Name(Required)

First Last

Renewal ID(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Email(Required)

Date of Birth(Required)

Occupational Licensing of Uniformed Service Members, Veterans, and Spouses.

Pursuant to Act 135 of 2021, ADH shall grant such automatic licensure upon receipt of payment of the initial licensure fee; evidence that the individual holds a substantially equivalent license in another state; and evidence that the qualified applicant is:(Required)

A uniformed service member stationed in the State of Arkansas.

A uniformed service veteran who resides in or establishes residency in the State of Arkansas.

Spouse of a uniformed service member assigned a tour of duty that excludes spouse and spouse relocates to the state of Arkansas.

Spouse of a uniformed service member who died in the line of duty and the spouse establishes residency in the State of Arkansas.

Not applicable.

Initial Licensure Fee Waiver

Pursuant to Act 725 of 2021, an applicant may receive a waiver of the initial licensure fee, if eligible. Eligible applicants who provide documentation showing their receipt of benefits from the appropriate State Agency and who(Required)

Receive assistance through the Arkansas, or current state of residence equivalent, Medicaid Program, or the Supplemental Nutrition Assistance Program

Are approved for unemployment within the last twelve (12) months

Have an income that does not exceed two hundred percent (200%) of the federal poverty income guidelines

Not applicable

Current Credential(s) Held (*Be sure to indicate level of credential in space provided):

Examples: BEI; CCHI; Court Qualified; EIPA; ESSE; MICS; Provisional; QAST, and RID.(Required)

Note: Copies of all credentials held for the current application year MUST be submitted along with this application. Credential(s) must show an expiration date and be valid for the year applicant is applying. Only 1 pdf upload is allowed per application; additional documents should be emailed to [email protected]

Statements of adherence to the Code of Professional Conduct:

A Licensed Qualified Interpreter must abide by the Professional Code of Conduct promulgated under these Rules and stated in Ark. Code Ann. § 20-14-805(b)(9). By signing this document, I agree to adhere to the ethical practices stated in the Professional Code of Conduct and Ark. Code Ann. § 20-14-805(b)(9). I further confirm that all information contained above is true and accurate.

Electronic Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Reduced application fees for 2024 license year indicated below:(Required)

$5.00 – Initial Application & Licensure

$4.00 – Annual License Renewal

$5.50 – Renewal plus late fee (Jan. 1 – 31st)

$7.00 – License Re-activation total (after Feb. 1)

$2.00 – Upgraded License

$1.00 – Replacement Card

Total Amount Included: Note: Insufficient funds will result in a $35 fee charged to the applicant’s account(Required)

Use this space to explain your reason for consideration of a late fee waiver and reinstatement of your license.

Online Payment? Visit The Online Payment Page, follow directions, Print Receipt. Otherwise, please mail your payment to the below address: Arkansas Department of Health 4815 West Markham Street, Slot 29 Little Rock, AR 72205

Upload Required Documents(Required)

Max. file size: 50 MB.

PHAB

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72205-3867
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