Alc/Drug Counselor -- CEU Waiver

Public Health: Office of practitioner licensing and certification - Alcohol And Drug Counselor

DPH Data Management and Governance (PLIS)
Continuing Education Waiver/Extension Request
License Number:
Name

First NameLast Name
Address of Record:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Application for (Please check one) :
I, First Name* Last Name* being duly sworn, declare my eligibility for a waiver/extension of the continuing education requirements:
1. I hereby declare my eligibility for a waiver/extension of the continuing education

requirements based on a medical disability/illness pursuant to the provisions of Section 2 of

Public Act 03-118. I certify that due to a medical disability/illness, I am unable to complete

the continuing education requirements from Date* to Date*
2. I further declare that I will meet the continuing education requirements as outlined in Section 2 of Public Act 03-118 after the dates indicated above.

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

MonthDayYear
Signature:
Subscribed and Sworn before me thisday* day of month* ,
20year* .
Notary Public:
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
Should be Empty: