Ky Lpcc Online License PDF Details

The Ky Lpcc online license form is a great way to renew your license if you are a licensed professional clinical counselor in the state of Kentucky. The process is quick and easy, and you can complete it from the comfort of your own home. Just be sure to have all of your information ready beforehand, including your license number and date of birth. Once you have submitted the form, you will receive an email confirmation with further instructions.

Below is the information in regards to the form you were in search of to fill out. It can tell you the span of time you'll need to fill out ky lpcc online license, what parts you will have to fill in and a few other specific details.

QuestionAnswer
Form NameKy Lpcc Online License
Form Length2 pages
Fillable?Yes
Fillable fields25
Avg. time to fill out5 min 34 sec
Other nameskentucky lpcc license verification, ky renewal lpca, renewal lpca kentucky, lpca license renewal ky

Form Preview Example

2011 Edition

KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS

PO BOX 1360

FRANKFORT KY 40602

http://lpc.ky.gov

RENEWAL APPLICATION FOR LICENSED PROFESSIONAL CLINICAL COUNSELOR

Your Licensed Professional Clinical Counselor credential expires on October 31, 2011. In accordance with KRS 335.535 and regulations (201 KAR 36:020) governing this profession, you are required to renew your license annually with the transmittal of this form and a renewal fee of $150.00, (check or money order) made payable to the Kentucky State Treasurer. Please return this completed form with the fee to the address above prior to the deadline date of October 31,2011. The fee for renewals received during the 60 day grace period is $25.00. Credentials not renewed prior to December 31,2011 will be terminated and you must immediately CEASE AND DESIST (no exceptions) the use of the title Licensed Professional Clinical Counselor in Kentucky.

If your renewal reminder indicated that you had been selected for AUDIT please send copies of evidence of having completed 10

hours of continuing education as defined in 201 KAR 36:030.

PLEASE COMPLETE ALL OF THE FOLLOWING:

Name

 

 

Present place of employment

 

Address

 

 

Address

 

 

Address

 

 

Address

 

 

City

State

Zip

City

State

Zip

Home telephone number

 

 

Business telephone #

 

Home e-mail address

 

 

Business e-mail address

 

_______________________________________________

License number

 

 

Social Security Number

 

 

 

 

 

(Please complete hack page ofrenewalform)

2011 Edition

1. Have you been convicted of a felony since your last application or renewal? “Conviction” including all instances in

which a plea of no contest is the basis of the conviction.

(

)No

(

 

)Yes

If yes, list offense and provide details on a separate sheet of paper.

 

 

 

 

 

2. Have you been subject to disciplinary action by a mental health credentialing board?

(

)No

 

(

) Yes

If yes, give details on a separate sheet of paper.

 

 

 

 

 

3.List any state in which you have become licensed or certified since your last renewal, the type of license or certification, and the number of the certification or license:

4. Are you currently serving in the military? (

) No

(

) Yes

5.If you are currently eligible to supervise LPCA’s please provide date of completion of required supervision training: Date of Board Approved Supervision Training

CERTIFICATE OF COMPLIANCE

I do certify under penalty of law that the information contained herein is true, correct, and complete to the best of my knowledge and belief. I am aware that, should investigation at any time disclose any such misrepresentation or falsification, my license could be subject to disciplinary action by the Kentucky Board of Licensed Professional Counselors

I have completed

hours of continuing education during the annual period for renewal as defined in 201 KAR 36:030.

If your renewal application indicates that you have been selected for AUDIT please send copies of evidence ofhaving completed 10

hours ofcontinuing education as defined in 201 KAR 36:030.

Signature:

Date:

/________ /________

 

(Sign your name - Do not print or type)

 

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