KENTUCKY BOARD OF SOCIAL WORK License Type: 43-44 Fountain Place LIC NO: Frankfort, KY 40601 APPLICATION FOR RENEWAL YOU MAY RENEW 90 DAYS IN ADVANCE OF EXPIRATION DATE. First: Renew License Online and Receive a  Last: Wallet Size Card Street: bsw.ky.gov City: State: Zip:

License Expiration Date:

Under the provisions of KRS 335.130, each Licensed Social Worker ($75), Certified Social Worker ($125), and Licensed Clinical Social Worker ($200) shall renew his or her license every three (3) years, and shall pay a renewal fee established by the board. If you desire to renew for the next three (3) years, renew online or mail this application together with the required fee (payable to the Kentucky State Treasurer) to this office before the expiration date shown above. Pursuant to KRS 335.130(1), a licensee shall renew his or her license on a three (3) year basis in order to continue to practice social work in Kentucky. (See page three for details.)

PLEASE COMPLETE THE FOLLOWING: 1. Note changes in mailing address if necessary: Name: ______Address: ______Home Phone No.: ______Home E-Mail Address: ______

2. Present employer and address (Required): Name: ______Address: ______Bus. Phone No.: ______Business E-Mail Address: ______

3. Last four digits of Social Security No. ______

4. Have you been convicted of a felony or misdemeanor since the last renewal of your license? No Yes If yes, what offense and attach an official/ certified court record of conviction: ______5. Has your license as a social worker in Kentucky or any other state been subject to disciplinary action? No Yes. If yes, give details and attach official licensure board records: ______

I certify that all information provided on this form is true, correct, and complete to the best of my knowledge and belief. I acknowledge that my license may be subject to disciplinary action if the information provided on this form is falsified.

SIGNATURE: ______DATE: ______CONTINUING EDUCATION INFORMATION You are required to list your continuing education information on this form. Forms submitted incomplete or incorrectly will be returned. You are not required to attach copies of your continuing education certificates with your renewal form. It is your responsibility to maintain certificates of attendance.

Title of Course Name of Presenter Name of Sponsoring Organization Provider or Date(s) Number of Approval # Attended CEU’S credits REQUIRED 1. List KY Social Work Ethics For Renewal here:

2. List Suicide Prevention Training Program here:

Total Number of CEU’S obtained ______To renew your license online, please go to bsw.ky.gov and follow the prompts for renewing online. Please allow up to 2 weeks for processing this renewal – you will receive an email confirmation. You may go to bsw.ky.gov after that time to confirm your renewal & print your official verification of license.