Licensure Number * (If not applicable, please put N/A.):N/A
Affirmation Clause *:I hereby affirm that I understand and have met the continuing education requirements for renewal (ie. 20 hours of education related to the field of youth with sexually harmful behaviors).
Since you last renewed, has any healthcare license, certificate, registration, or permit you hold or have held been disciplined or are formal charges pending? *: No
Since you last renewed, have you been denied a license, certificate, registration, or permit in any state? *: No
Since you last renewed, and except for minor violations of traffic laws resulting in fines and arrests or convictions that have been expunged by a court, have you been arrested, entered into a diversion agreement, been convicted of, pled guilty to, or pled nolo contendere to any offense, misdemeanor, or felony in any state? *: No
Since you last renewed, have you had a malpractice judgment against you or settled a malpractice action? *: No
Since you last renewed, have you been denied staff membership or privileges in any hospital or health care facility or, have staff membership or privileges been revoked, suspended, or subjected to any restriction, probation, or other type of discipline or limitations? *: No
:I hereby affirm that the statements made in this application are true and complete and correct.*