1. Name ________________________________________________________________________

                    First                                             Middle/Maiden                             Last

(Check if new address _______)

2. Mailing Address ________________________________________________________________

                                    P O Box/Street                                             City/State                                 Zip

3a. Employment Name ______________________________________________________________

b. 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)

Which address is to be used on website _________ Home _______ Office

7. SSN _______-_______-__________8: Highest Degree Awarded/ University _____________________

9. License Number _______________________Issue Date_______________________

10. Other professional licenses or national certifications ________________________________________________

___________________________________________________________________________________________

11. 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.

12. 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.

I have _____completed and signed Renewal Application front only (back if audit slip is attached to renewal form or if the renewal

                        is submitted after June 30, 2005).

_____attached all continuing education documentation; (if audit slip is attached to renewal form or if the renewal is

            submitted after June 30, 2005).

_____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 postmarked after June 30, 2005 .  MUST ALSO INCLUDE DOCUMENTATION FOR 40 HOURS OF CEH'S.

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