Application For Reinstatement Of License

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF CONSUMER AND REGULATORY AFFAIRS OCCUPATIONAL AND PROFESSIONAL LICENSING ADMINISTRATION P.O. BOX 37200, WASHINGTON, D.C. 20013-7200 INSTRUCTIONS FOR REINSTATEMENT APPLICATION 1. Complete ALL items. If an item does not apply to you enter "N/A". Incomplete or incorrect applications will be returned. Application must be accompanied by application fee of $50.00, check or money order, payable to D.C. TREASURER. A charge of $50.00 will be imposed for dish onored check (Public Law S9-208). All fees are earned when paid and are not transferable or refundable. YOU WILL BE BILLED FOR THE RENEWAL FEE AFTER THE BOARD APPROVAL OF THE APPLICATION. 2. 3. Submit two (2) recent passport type photographs. 4. Practice outside the District of Columbia must be supported by an official letter verifying licensure in the applicable jurisdiction(s) during period(s) of practice. ( OU must contact that jurisdiction to request this Y information.) Submit copies of course certificates reflecting continuing professional education (if applicable to your profession) since last renewal to include names of courses, dates, instructor's signature and location. 5. THE SOLE RESPONSIBILITY IS ON YOU TO REQUEST THE INFORMATION TO PROCESS YOUR APPLICATION FOR LICENSURE AND TO FOLLOW-UP WITH THAT AGENCY FOR ANY POSSIBLE DELAYS. American LegalNet, Inc. www.USCourtForms.com GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF CONSUMER AND REGULATORY AFFAIRS OCCUPATIONAL AND PROFESSIONAL LICENSING ADMINISTRATION P.O. BOX 37200, WASHINGTON, D.C. 20013-7200 APPLICATION FOR REINSTATEMENT Date of Application Name: Type or Print Date of Birth: MO/DA/Yr. Home Address: Home Phone: Business Names: Business Address: Business Phone: Type of License: Date Issued: Original License Number: Date of Last Renewal: Social Security Number: Method of Original Licensure (Check One): ( ) Examination ( ) Reciprocity ( ) Waiver Reason for not renewing: Please account for all employment, periods of non-employment, and all practice since the last date of licensure, and indicated the name, business address and telephone number of all such employment in the District of Columbia and other jurisdictions. (Attach Additional Sheets. if necessary) American LegalNet, Inc. www.USCourtForms.com Have you (if firm, any office of firm) been arrested, indicted or convicted of a crime (other than minor traffic violations) since your last renewal? Yes _____ No ______ If "Yes", attach a written explanation. Has any jurisdiction denied your application for registration, suspended or revoked your registration or informed you of any pending charges since your last renewal? Yes ______ No ______ If "Yes", attach a written explanation AFFIDAVIT OF APPLICANT , being duly sworn, depose and I says under penalty of false statement, that the information given in this application, , including all writing and exhibits attached hereto, is true and complete. Signature of Applicant District of Columbia ss. Subscribed and sworn to before me this day of 20 by the affiant, who personally appears before me. (SEAL) Notary Public FOR OFFICE USE ONLY Original License Number: Date of last license renewal: Employment verified by: Board Approved by: Signature Date Date My Commission Expires Verified by Verified by Date Initials Initials Board Denied by: Signature REMARKS: American LegalNet, Inc. www.USCourtForms.com