Acupuncturist--Application for Waiver or Time Extension for CE

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
PRACTITIONER LICENSING AND INVESTIGATIONS SECTION Acupuncture Licensing

AFFIDAVIT
Waiver of continuing education due to medical disability/illness
I hereby declare my eligibility for a waiver of the continuing education requirements based on a medical disability/illness pursuant to Connecticut General Statutes. I certify that due to a medical disability/illness, I am unable to complete the continuing education requirements from Date* to Date .

I am hereby attaching certification from my health care provider.

The above statements are true to the best of my knowledge and belief.
Date

MonthDayYear
Signature
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Address

Street Address

City, State, Zip

CityState / Province

Postal / Zip Code
License Number
License Number
Subscribed and Sworn before me this Day day of Month of 20 Year (YY) .
Notary Public
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Phone: (860) 509-7603
Telephone Device for the Deaf (860) 509-7191
410 Capitol Avenue – MS # 12MQA
P.O. Box 340308 Hartford, CT 06134
An Equal Opportunity Employer
This is a non-smoking facility.
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