Looking for a License Application Form Templates? Download it for free!

BUREAU USE ONLY

BUREAU OF OCCUPATIONAL LICENSES

Receipt #

__________

1109 Main St., Suite 220

Boise, Idaho 83702-5642

Date Rec’d __________

(208) 334-3233

Date Issued __________

LOST, DESTROYED, OR INVALID LICENSE APPLICATION

INSTRUCTIONS

The fee of $10.00 ($25.00 for Real Estate Appraisers) together with this completed application must be

submitted to the Bureau of Occupational Licenses, for issuance of a certified copy or duplicate of a lost,

destroyed, or invalid certificate, license or permit as set forth in Idaho Code Section 67-2613. (NOTE: The

affidavit will not be processed unless the required fee is enclosed. If the fee is waived, it will be refunded.)

_____________________________________________________, being first duly sworn deposes and affirms

please print or type full name of licensee

that she ( ) or he ( ) is the legal and lawful owner of license, certificate, or permit number______________.

complete license number

Said license, certificate, or permit entitles the person named above to engage in the profession of

_________________________________________________________________________________________

please print or type profession

in the State of Idaho in accordance with the applicable laws and rules of the regulatory board governing said

practice. The original license, certificate, or permit identified above has been lost, destroyed, or does not bear a

valid name of said lawful owner. Said owner hereby makes application for the issuance of a certified duplicate

or replacement of said license, certificate, or permit by the State of Idaho, Department of Self- Governing

Agencies, Bureau of Occupational Licenses, in accordance with Idaho Code, 67-2613.

The original document identified above is not in my possession, or is invalid because: (please print or type the

facts surrounding the loss or destruction of the license, certificate, or permit in question. If you are requesting a

replacement, due to a name change, a completed Name Change Affidavit must be on record with the Bureau,

and all original licenses, certificates, or permits must accompany this application.)

__________________________________________________________________________________________

________________________________________________

Signature of Applicant (must be notarized below)

State of ______________, County of _________________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

________________________________________________

(seal)

Notary Public official signature

residing at _______________________________________

my commission expires ____________________________

BOL-LLA-09/00

Lost, Destroyed, Or Invalid License Application Form - Bureau Of Occupational Licenses, State Of Idaho