MFT: CEU Waiver

Public Health: Office of practitioner licensing and certification - Marital And Family Therapist

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. During the exemption period from Date* to Date* I did

not/will not actively engage in the practice of marital and family therapy in the State of Connecticut;

OR

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 Regulations of Connecticut State Agencies Section 20-195c-6. 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 Regulations of Connecticut State Agencies Section 20-195c-7 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:

Public Health: Office of practitioner licensing and certification - Marital And Family Therapist

Continuing Education Waiver/Extension Request