Psychologist: CEU Waiver

Public Health: Office of practitioner licensing and certification - Psychology Affidavit

DPH Data Management and Governance (PLIS)
Application for (Please check one) :
I, First Name* Last Name* being duly sworn, attest that:
1. I am a psychologist licensed in the State of Connecticut.

2. During the exemption period from   Date *   to    Date *   I did not/will not actively engage in the practice of psychology 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 Section 20-191c(d), 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*
3. I, therefore, claim an exemption for the above-specified period from the requirements of Section 20-191c(a), Connecticut General Statutes, which specifies that each licensed psychologist shall complete a minimum of ten (10) hours of continuing education during each twelve-month period for which a license is being renewed.

4. I understand that, should I resume the practice of psychology in the State of Connecticut, I must complete the requirements listed in Section 20-191c(e), Connecticut General Statutes, which specifies that each licensee actively engaged in the practice of psychology must complete a minimum of five (5) contact hours of continuing education not later than six months after the date on which such licensee returns to active practice. In addition, such licensee shall comply with the certificate of completion requirements prescribed in 20-191c (c).

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

MonthDayYear
Signature:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Connecticut Psychology License Number:
Phone Number/Email Address:
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 - Psychology Affidavit