1. Name First Middle/Maiden Last ________________________________________________________

    (Check if new address)________

2. Mailing Address/ P. O. Box/Street City/State Zip 

 __________________________________________________________________________________

3. Employment Address/ P. O. Box/Street City/State Zip

__________________________________________________________________________________

4. Home Telephone (_____ )____________ Work Telephone (_____ )_______________________

5. E-mail ________________________________ 

6. Board Approved Supervisor ___Yes ___ No (for Counselor Interns)

7. Which address is to be used on website ____ Home ____ Office

8. SSN ________-_____-___________________

9. Highest Degree Awarded/ University ____________________________________

10. License Number Issue Date __________________________

11. Other professional licenses or national certifications__________________________________________

12. Have you had any other professional license/certification revoked/suspended since issuance of your license ?

    (    )Yes (    ) No  If yes, please explain on a separate sheet.

13. Have you been convicted of a felony or a first degree misdemeanor since issuance of your license?

    (    ) Yes (    ) No  If yes, Please explain on a separate sheet.

Checklist:

I have _____completed and signed Renewal Application -FRONT ONLY unless audit slip is attached;

            _____attached all continuing education documentation; (if I have audit slip attached to application).

            _____enclosed the $150.00 renewal fee; personal check accepted (non-refundable)

            _____enclosed an additional $25.00 for a duplicate license;

            _____enclosed an additional $50.00 to change my name and get a new license

                         (include documentation showing name change) driver's license, marriage license etc.

            _____late fee of $50.00 if post marked after June 30, 2003.   ^{MUST INCLUDE DOCUMENTATION FOR 40 HOURS OF CEH'S.}               

Statement of Understanding:

I hereby apply for licensure renewal by the Licensed Professional Counselors Board of Examiners.

I understand that renewal is contingent upon satisfactory completion of all requirements. Should I

furnish any false information in this application, I hereby agree that such act shall constitute cause for

the suspension or revocation of the license to practice mental health counseling in the State of Louisiana

and forfeiture of the renewal fee.

I certify that I have completed a minimum of 40 Continuing Education Hours as defined in Louisiana Administrative

Code Title 46, Part LX, §§801 and 803.

Signature __________________________                                                      _______ Date __________________

Return to: Licensed Professional Counselors Board of Examiners

8631 Summa Avenue

Baton Rouge LA 70809

Back of form is used only for those being audited.

DIRECTIONS:

Please list continuing education hours (CEH's) below.

You need list no more than the 40 CEH's needed for renewal.

If additional space is  needed, attach a separate sheet with the same information.

For assistance in filling out this form, see the enclosed instructions for Reporting Continuing Education.

TOTAL CEH's ___________

CONVERSION SCALE CEH = Continuing Education Hour, CEU = Continuing Education Unit

1.0 Clock Hour = 1.0 CEH, 4.0 CEH's = 40 CEH's, 3.0 Semester Hours = 45 CEH's