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 __________________________________________________________________________________

4. Home Telephone ( ______) _________________ Work Telephone (______) ___________________

5. E-mail _______________________________ 6. Board Approved Supervisor ( for Counselor Interns) _____ Yes _____ No

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, 2006).

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

is submitted after June 30, 2006).

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, 2006. MUST ALSO INCLUDE DOCUMENTATION FOR 40 HOURS OF CONTINUING EDUCATION

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

8631 Summa Avenue

Baton Rouge LA 70809