LPC - Professional Licensing Boards

7.
A
Itemize your remaining continuing education activities in this table. Limit your entries to those necessary to meet the forty-five (45) contact
hour requirement. List only one (1) program per line. If more space is needed, attach a page with a list of the additional activities in the same
format as the table provided.
DATE(S)
COURSE/ACTIVITY
PROGRAM
SPONSOR
CONTACT
HOURS
B
C
D
E
F
G
TOTAL CONTACT HOURS SUBMITTED INCLUDING ETHICS
8. During the last three (3) years, has any state rejected your application for licensure and/or certification Yes No
9. During the last three (3) years, has any state revoked, suspended, refused to renew, or otherwise restricted your license
and/or certification
10. During the last three (3) years, have you voluntarily surrendered your license and/or certification in order to avoid
disciplinary action by a regulatory agency
11. During the last three (3) years, have you been sanctioned by a professional association Yes No
12. During the last three (3) years, have you been convicted of a misdemeanor involving moral turpitude (A plea of no
contest shall create a presumption of guilt to the underlying criminal charges.)
13. During the last three (3) years, have you been convicted of a felony (A plea of no contest shall create a presumption of
guilt to the underlying criminal charges.)
14. Are you addicted to the use of alcohol, any narcotic, or other drugs having similar effects to an extent or in a manner
dangerous to yourself, any other person or the public, or to an extent that use impairs your ability to provide services
with safety to the public
15. Has a court of competent jurisdiction ever judged you incompetent Yes No
16. During the last three (3) years, have you violated and been convicted of a charge under the Wyoming Controlled
Substances Act
If you answered "Yes" to any of the previous questions you are required to provide documentation relative to your "Yes" answer in order for your
renewal application to be considered. Documentation shall include, but not be limited to, certified copies of court records, letters of sanction, state
board disciplinary action documents, etc. Attach supporting documents to this application.
WARNING
Making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2)
years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 6-5-303.)
AFFIDAVIT
I am the person making the foregoing statements and that they are made in good faith and are true in every respect. I have read, understand, and
agree to abide by the Rules and Regulations promulgated by the Mental Health Professions Licensing Board, and W.S. § 33-38-101 through 113.
I have satisfied the Continuing Education requirement for the renewal of my license. I understand that I may be selected for audit of my Continuing
Education and may be subject to disciplinary action should I misrepresent my compliance.
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
SIGNATURE OF APPLICANT
DATE
Revised 8/2013