Acupuncturist--License Reinstatement Application

  • STATE OF CONNECTICUT
    DEPARTMENT OF PUBLIC HEALTH
    Acupuncturist Licensing
    Email: dph.dentalteam@ct.gov
    Web Site: www.ct.gov/dph/license
    Acupuncturist License Application

  • Tape a recent photo
    of applicant in this
    space.
    DO NOT STAPLE

  • Please complete this application and submit it along with a check or money order in the amount of $200.00, made payable to "Treasurer, State of Connecticut." Return your completed application and fee to:
    CT DPH, Application Processing, 410 Capitol Ave., MS# 12MQA, PO Box 340308, Hartford, CT 06134

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender*
  • Ethnicity: check (✔︎)*
  • Race: Please check (✔︎) all that apply*
  • Have you held a Connecticut acupuncturist license in the past?*
  • Have you ever been censured, disciplined, dismissed or expelled from, had admissions monitored or restricted, had privileges limited, suspended or terminated, been put on probation, or been requested to resign or withdraw from any of the following: Any hospital, nursing home, clinic, or similar institution; Any health maintenance organization, professional partnership, corporation, or similar health practice organization, either private or public; Any professional school, clinical clerkship, internship, externship, preceptorship; or postgraduate training program; Any third party reimbursement program, whether governmental or private?*
  • Have you ever had your membership in or certification by any professional society or association suspended or revoked for reasons related to professional practice?*
  • Has any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction, limited, restricted, suspended or revoked any professional license, certificate, or registration granted to you, or imposed a fine or reprimand, or taken any other disciplinary action against you?*
  • Have you ever, in anticipation or during the pendency of an investigation or other disciplinary proceeding, voluntarily surrendered any professional license, certificate or registration issued to you by any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction?*
  • Have you ever been subject to, or do you currently have pending, any complaint, investigation, charge, or disciplinary action by any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction or any disciplinary board/committee of any branch of the armed services? You need not report any complaints dismissed as without merit?*
  • Have you ever entered into, or do you currently have pending, a consent agreement of any kind, whether oral or written, with any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, any branch of the armed services or a foreign jurisdiction?*
  • Have you ever been found guilty or convicted as a result of an act which constitutes a felony under the laws of this state, federal law or the laws of another jurisdiction and which, if committed within this state, would have constituted a felony under the laws of this state?*

  • If you answered yes to any of the above questions regarding your professional history, please provide full details and provide supporting documentation (e.g. certified court copy with court seal affixed, complaint, answer, judgment, settlement or disposition) that will assist this office’s review.

  • Are you now, or have you ever been, licensed as an acupuncturist in any other state?*
  • Start Date*
     - -
  • Grad Date*
     - -
  • Start Date
     - -
  • Grad Date
     - -

  • NOTARIZATION: On this    day of       20    , the above referenced individual personally appeared before me, who being duly sworn says that he/she is the person referred to in the foregoing application, the photograph attached hereto is a true picture of self and that the statements made herein or on any document attached hereto are true in every respect. 

    Sworn to before me this    day of      20     .

  • My commission expires
     - -
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  • Should be Empty: