4. Statement of Compliance for Professional Development Hours (PDHs) [NAC 625.430]

You must check Active or Inactive below. License may become Inactive if PDHs are not reported correctly.

ACTIVE I have complied with the Board’s continuing education requirement. (30 PDHs minimum)
Nevada residents must enter their PDHs.
I do have documentation in my files. Do not send PDH documentation unless requested.

ACTIVE resident of another state; I have complied in another state (other than Nevada) and that state's continuing education requirements are substantially equivalent to those in Nevada.

INACTIVE I did not meet the 30 PDH continuing education requirement for this period.

• If you choose Inactive you must answer all questions, sign the affidavit at the bottom of the form, and submit payment shown in "Amount Due".

Exempt I did not acquire the 30 PDHs of continuing education because of the following

exemption pursuant to NAC 625.440. Send documentation, must be approved by the Board.

• This is my first renewal (licensed less than 2 years).

• I had a serious illness during this period.

• I served more than 120 days on active military duty during this period.

• I worked outside the United States for a minimum of 120 days this period.

5. Declarations:

Mark selections and sign the signature block. [ Renewals will not be accepted unless the forms are properly completed and signed. ]

DISCIPLINARY DECLARATION

NO, I have not been disciplined by any licensing jurisdiction within the past two years.

YES, I have been disciplined by any licensing jurisdiction within the past two years.

( If Yes, describe in full in the area below and submit with this form. )

CRIMINAL CONVICTION DECLARATION

Since your last license renewal (or application approval if this is your first license renewal), have you been convicted of a gross misdemeanor or felony?

Yes No

CHILD SUPPORT DECLARATION

In compliance with the Federal Welfare Reform Act and the Nevada State Welfare Division, the 1997 session of the Nevada Legislature enacted NRS 625.387. This requires that all professional and occupational licensing agencies add specific questions regarding child support to all applications for new licenses and license renewals.

I am not subject to a court order for payment of child support.

I am subject to a court order for payment of child support for one or more children, and I am in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the payment of the amount owed pursuant to the order.

I am subject to a court order for the support of one or more children, and I am not in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the payment of the amount owed pursuant to the order