License Renewal Application Form (License #: Psy- ) - 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 #: PSY-

Expiration Date: June 30 of each year

Renewal Fee: $200.00

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

____________________________________________________________________________________________________________

GUIDELINES FOR APPROVAL OF CONTINUING EDUCATION CREDITS.

CONTINUING EDUCATION CREDIT WILL BE GIVEN TO FORMALLY ORGANIZED WORKSHOPS OR CLASSES WITH AN ATTENDANCE

ROSTER AND PRE-ASSIGNED CONTINUING EDUCATION CREDIT OFFERED IN ASSOCIATION WITH OR UNDER THE AUSPICES OF:

REGIONALLY ACCREDITED INSTITUTIONS OF HIGHER EDUCATION.

THE AMERICAN PSYCHOLOGICAL ASSOCIATION.

A REGIONAL PSYCHOLOGICAL ASSOCIATION.

A STATE PSYCHOLOGICAL ASSOCIATION.

CREDIT WILL BE GIVEN FOR THE NUMBER OF CREDIT HOURS PRE-AUTHORIZED BY THE SPONSORING AGENCY WITH NO

UPPER LIMIT ON THE NUMBER OF HOURS.

SIX (6) HOURS OF CONTINUING EDUCATION CREDIT WILL BE ALLOWED FOR DOCUMENTED ATTENDANCE AT INTERNATIONAL,

NATIONAL AND REGIONAL MEETINGS OF PSYCHOLOGICAL ORGANIZATIONS.

OTHER RELEVANT WORKSHOPS, CLASSES OR TRAINING EXPERIENCES MAY RECEIVE UP TO SIX (6) HOURS OF CREDIT PER

EXPERIENCE PROVIDED THEY ARE CONDUCTED BY A LICENSED OR REPUTABLE PSYCHOLOGIST OR OTHER MENTAL HEALTH

PROFESSIONAL. EACH DOCUMENTED HOUR OF TRAINING EXPERIENCE COUNTS AS ONE (1) HOUR OF CONTINUING EDUCATION

EXPERIENCE. A MAXIMUM OF SIX (6) HOURS OF THIS TYPE OF EXPERIENCE MAY BE APPROVED.

PRESENTATION OF PAPERS AT INTERNATIONAL, NATIONAL, REGIONAL OR STATE PSYCHOLOGICAL OR OTHER PROFESSIONAL

ASSOCIATIONS MAY BE COUNTED AS EQUIVALENT TO SIX (6) HOURS PER EVENT.

THE BOARD ALSO RECOGNIZES THE VALUE OF SELF-STUDY, LECTURES OR PUBLIC OR PROFESSIONAL PUBLICATIONS AND

PRESENTATIONS (INCLUDING FOR EXAMPLE, IN THE CASE OF THE UNIVERSITY FACULTY, PREPARATION OF A NEW COURSE).

THEREFORE, THE BOARD WILL ALLOW CREDIT FOR SIX (6) HOURS OF INDIVIDUAL STUDY PER YEAR.

NEWLY LICENSED INDIVIDUALS WILL BE CONSIDERED TO HAVE SATISFIED THE CONTINUING EDUCATION REQUIREMENTS FOR

THE REMAINDER OF THE YEAR IN WHICH THEIR LICENSE IS GRANTED.

AFFIDAVIT

I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT DURING THE LAST 12 MONTHS I HAVE MET THE CONTINUING EDUCATION

REQUIREMENTS APPLICABLE TO THE LICENSE NOTED ABOVE BY COMPLETING A MINIMUM OF 20 FULL HOURS OF CONTINUING

EDUCATION CREDITS, IN ACCORDANCE WITH RULE 402.

I ACKNOWLEDGE THAT PROOF OF ATTENDANCE DOCUMENTATION FOR

SAID CE MAY BE REQUESTED AND THAT FAILURE TO SUBMIT THE REQUESTED DOCUMENTATION MAY RESULT IN ACTION AGAINST

MY RIGHT TO LICENSURE.

SIGNATURE _________________________________________________

PLEASE SEE THE ATTACHED FORM IF YOU CURRENTLY SUPERVISE A SERVICE EXTENDER.

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

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