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I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief made in good faith.

I have completed at least twenty (20) hours of continuing education from July 1, 2024 to June 30, 2025 according to Arkansas Psychology Board Rules Section 9., with (3) three of the (20) twenty hours being in ethics. Exceptions are in Section 9.2.A and/or 9.2.B.

Questions about a surrendered, denied, suspended or revoked license related to ethical complaints and disciplinary actions. This excludes not renewing a license due to moving to another state.

Have you ever been convicted of a felony?

Have you ever had employment, work assignment, volunteer posting, job duties, and/or job duty locations terminated, suspended and/or altered due to Substance Abuse?

Have you ever had employment, work assignment, volunteer posting, job duties, and/or job duty locations terminated, suspended and/or altered due to Mental Impairment?

Have you ever had employment, work assignment, volunteer posting, job duties, and/or job duty locations terminated, suspended and/or altered due to Sexual Misconduct?

Have you ever had disciplinary action taken against your psychology license/certificate in ANY state or province?

Has any disciplinary action, limitation, restriction or rehabilitation been initiated or entered against your psychology license/certificate in any state or province?

Have you ever applied for and been denied, or had suspended or revoked, licensure/certification in ANY state/province as a provider of psychological services?

Have you ever surrendered a psychology license/certificate in ANY state/province?

Have you ever applied for and been denied, and/or suspended or revoked, membership in any professional psychological association?

EXCLUDING PSYCHOLOGY LICENSURE: Has any disciplinary action, limitation, restriction, or rehabilitation been initiated or entered against any PROFESSIONAL license or certificate in ANY state or province?

EXCLUDING PSYCHOLOGY LICENSURE: Has a request for any type of PROFESSIONAL license or certificate ever been denied or revoked in ANY state or province?

EXCLUDING PSYCHOLOGY LICENSURE: Have you ever surrendered a PROFESSIONAL license/certificate in ANY state/province?

If you are a supervisor, did you submit your annual report? If you are a supervisee, did you submit your annual report? If you are not a supervisor or supervisee, then select YES.

Attestation

Arkansas Psychology Board
4815 W. Markham, Slot 80
Little Rock, AR72205
(501) 682-6167

SUBMITTING YOUR ANSWERS...

Welcome to the attestation portion of your renewal process. Answer the questions below truthfully and if the board requires further information, you will be notified at a later date.

IMPORTANT: PLEASE READ EACH QUESTION CAREFULLY

Attestation

Arkansas Psychology Board 4815 W. Markham, Slot 80Little Rock, AR72205(501) 682-6167

SUBMITTING YOUR ANSWERS...

Welcome to the attestation portion of your renewal process. Answer the questions below truthfully and if the board requires further information, you will be notified at a later date.

IMPORTANT: PLEASE READ EACH QUESTION CAREFULLY

Arkansas Psychology Board
4815 W. Markham, Slot 80
Little Rock, AR72205
(501) 682-6167