Waiver of Continuing Education while not actively practicing: 

I,   First Name*   Last Name*     being duly sworn, attest that:

1. I am a licensed clinical speech and language pathologist 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 speech and language pathology in the State of Connecticut;
3. I, therefore, claim an exemption for the above-specified period from the continuing education requirements that specifies that each licensee actively engaged in the practice of speech and language pathology must complete a minimum of 20 contact hours during the registration period.
4. I understand that, should I resume the practice of speech and language pathology in the State of Connecticut, I must complete 7 hours of continuing education within six (6) months of returning to active practice. 

OR,

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 Section 20-411a(f), 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*   

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

Subscribed and Sworn before me thisday* day of month*, 
20 year*