License Renewal Application Form (License #: Sw-) - State Of Idaho printable pdf download

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 #: SW-

Expiration Date: June 30 of each year

Renewal Fee: $40.00

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

____________________________________________________________________________________________________________

BEGINNING ON JULY 1, 1995, ANNUAL CONTINUING EDUCATION WAS REQUIRED FOR THE RENEWAL AT ALL LEVELS OF SOCIAL

WORK LICENSURE IN IDAHO.

AN ANNUAL MINIMUM OF 20 CONTINUING EDUCATION (CE) HOURS ARE REQUIRED TO RENEW EACH

LICENSURE LEVEL.

PLEASE REFER TO RULE 351 FOR THE COMPLETE CE REQUIREMENTS.

NOTE: INDIVIDUALS ORIGINALLY LICENSED BY THE SOCIAL WORK BOARD DURING THE PRECEDING 12 MONTHS ARE CONSIDERED

TO HAVE MET THE CONTINUING EDUCATION REQUIREMENTS. INDIVIDUALS WHO OBTAINED LICENSURE IN A DIFFERENT

CATEGORY OF SOCIAL WORK (MOVED FROM ONE LICENSE CATEGORY TO ANOTHER) DURING THE PREVIOUS 12 MONTHS MUST MEET

THE CONTINUING EDUCATION REQUIREMENTS.

DURING THE PAST 12 MONTHS HAVE YOU BEEN CONVICTED OF A FELONY OR ANY CRIME INVOLVING MORAL TURPITUDE,

ALCOHOL ABUSE, DRUG ABUSE, FRAUD, OR DECEIT?

[

] NO

[

] YES (IF YES, A COPY OF THE

CONVICTION ORDER MUST BE ATTACHED)

AFFIDAVIT

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

THE LAST 12 MONTHS.

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 MY RESPONSES TO THESE REQUESTS ARE TRUE AND CORRECT.

SIGNATURE_____________________________________________

License Renewal Application Form (License #: Sw-) - State Of Idaho

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