CE Extension Request

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General Instructions. Licensees on active status wishing to obtain an extension of time to satisfy the continuing education requirement must make application on this form. The extension request must be received by the Commission on or before June 10 of the license year for which the extension is sought for consideration of the request, including review of all supporting documentation and such verification of information as may be necessary. Applicants are referred to Commission Rule 58A.1709 regarding “Extensions of Time to Complete Continuing Education,” which is reprinted on page 2 of the printable form.

Personal Information

Licensee Name*

License Number*

Mailing Address*

City*

Mailing State*

9-Digit Zipcode Lookup*

Public Phone

Private Phone*

Public Email

Private Email*

Circumstance Details

Describe below the incapacitating illness or other circumstance for which reason the licensee is requesting an extension of time to satisfy the continuing education requirement. The description must include information regarding the specific length of time the incapacitating illness or other circumstance has affected the licensee’s ability to satisfy the continuing education requirement.*
Max characters allowed: 1000 *(If you need additional space please upload an attachment)

Document Upload

Include with this form objective evidence of the incapacitating illness or other circumstance such as a written statement from an attending physician or other authoritative documentation regarding the circumstances described in the licensee’s request. *
*Accepted File Types: .tiff .tif .jpeg .jpg .txt .pdf .docx .doc .png
*Max file upload size 10MBs total.

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Total File Upload Size: 0.000*Mb

*Selected file(s) size exceed upload limitations of 10MBs

Authorization

Signature Required*

(Type your name)

Date Signed

4/24/2024

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3.17.184.90

This form is not meant to be printed. If you have already completed the form please use the submit button at the bottom to send the form directly to the Commission.