2004 LMFT LICENSE RENEWAL APPLICATION

1. Name:___________________________________________________________________

             First                         Middle/Maiden                     Last

(Check if new address _______)

2. Mailing Address:______________________________________________________

P O Box/Street City/State Zip

3a. Place of Employment Name: ____________________________________________

b. Place of Employment address: ___________________________________________

P.O. Box/Street City/State Zip

4. Home Telephone: ( )__________Work Telephone: ( )__________________

5. E-mail _______________

6. Board Approved LMFT Supervisor _____ Yes _____ No

Which address to use in Board website listing _________ 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.

13. Have you had any changes in your specialty areas in the past 2 years?

( ) Yes ( ) No

Note: See §3503,A,7 and §4707:H. One course or workshop is not enough to make you a specialist or expert. Competency involves knowledge, experience, and supervision.

Checklist:

For All Renewals:

I have: _____completed and signed Renewal 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 postmarked after December 31, 2004 . MUST ALSO INCLUDE DOCUMENTATION FOR 40 HOURS OF CEH'S.

For Audited CEUs (An Audit Form is enclosed if you are being audited):

I have: _____attached all continuing education documentation on the back of this application

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 Licensed Marriage and Family Therapy in the State of Louisiana and forfeiture of the renewal fee.

I certify that I have completed a minimum of 40 Continuing Education Hours including 3 hours in marriage and family therapy ethics as defined in Louisiana Administrative Code Title 46, Part LX, §§3501 and 3503.

Signature___________________________________________________ Date__________________

Return To: Licensed Professional Counselors Board of Examiners

8631 Summa Avenue

Baton Rouge LA 70809

USE BACK OF FORM ONLY IF BEING AUDITED

Directions:

You do not need to list more that the 40 CEUs required for renewal.

Attach a separate sheet with the same information if you need additional space. A blank form is available at lpcboard.org if you wish to use a computer.

If additional space is needed, attach a separate sheet with the same information. For assistance in filling out this form, see the enclosed board rules for reporting LMFT CEUs.