License Renewal Application Form (License #: P)- Bureau Of Occupational Licenses

Owyhee Plaza

STATE OF IDAHO

(208) 334-3233

1109 Main St., Suite 220

BUREAU OF OCCUPATIONAL LICENSES

Boise Idaho 83702-5642

LICENSE RENEWAL APPLICATION

License #: P-

Expiration Date: June 30 of each year

Renewal Fee: $150.00

The above noted renewal fee is for the next 12 month period and must be submitted to this office before the expiration date, also

noted above. License renewals submitted after the expiration date require a reinstatement fee of $25.00 in addition to the renewal

fee noted above.

Please submit this form with the required fee (check or money order) to the address noted above.

ALL RETURNED CHECKS ARE SUBJECT TO A $20.00 COLLECTION FEE.

PRINT NAME & ADDRESS BELOW AS IT

NOTE ADDRESS CHANGES BELOW:

APPEARS ON YOUR EXPIRING LICENSE

(Name changes must be accompanied by official

documents authorizing said change.)

______________________________

Please write your license number on your check or money order

DO NOT SEND CASH

____________________________________________________________________________________________________________

AFFIDAVIT

DURING THE PAST 12 MONTHS HAVE YOU:

1. BEEN CONVICTED OF A FELONY OR ANY CRIME INVOLVING MORAL TURPITUDE, ALCOHOL ABUSE, DRUG ABUSE,

FRAUD, OR DECEIT?

[

] NO

[

] YES

2. RECEIVED ANY TYPE OF DISCIPLINARY SANCTION, RESTRICTION, OR LIMITATION BY A STATE OR FEDERAL

LICENSING AGENCY, HOSPITAL, OR HEALTH CARE ORGANIZATION?

[

] NO

[

] YES

3. VOLUNTARILY SURRENDERED OR STIPULATED TO SANCTIONS AGAINST YOUR LICENSE, HOSPITAL OR CLINICAL

PRIVILAGES, STAFF MEMBERSHIPS, OR DEA NUMBER?

[

] NO

[

] YES

4. BEEN DENIED LICENSURE, REGISTRATION, CERTIFICATION, MEMBERSHIP, PRIVILAGE, OR ANY OTHER

CREDENTIAL BY A STATE OR FEDERAL AGENCY, MEDICAL FACILITY, OR HEALTH CARE ORGANIZATION?

[

] NO

[

] YES

(A WRITTEN EXPLANATION AND DOCUMENTATION MUST ACCOMPANY THIS NOTICE FOR ANY "YES" ANSWER TO THE ABOVE

QUESTIONS.)

I CERTIFY THAT I HAVE MET THE CONTINUING EDUCATION REQUIREMENTS APPLICABLE TO THE LICENSE NOTED ABOVE DURING

THE LAST 12 MONTHS BY COMPLETING A MINIMUM OF TWELVE (12) FULL HOURS OF POST-GRADUATE PODIATRY EDUCATION

COURSES, NO MORE THAN SIX (6) HOURS OF WHICH WERE HOME STUDY.

I ACKNOWLEDGE THAT DOCUMENTATION OF ALL OR

PART OF SAID CONTINUING EDUCATION MAY BE REQUESTED AND THAT FAILURE TO SUBMIT THE REQUESTED DOCUMENTATION

MAY RESULT IN ACTION AGAINST MY RIGHT TO LICENSURE.

I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION ABOVE IS TRUE AND CORRECT.

SIGNATURE _________________________________________

License Renewal Application Form (License #: P)- Bureau Of Occupational Licenses - State Of Idaho

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