2005 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.

Checklist:

For All Renewals:

I have: _____completed and signed Renewal Application (first page only if not being audited)

_____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                  charge: driver=s license,  marriage license etc.)

          late fee of $50.00 if postmarked after December 31, 2005.  LATE  RENEWAL APPLICATIONS 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 than 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 www.lpcboard.org .

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.

Only those being audited need to complete page 2.