The applicant shall supply the following information on the application form for license renewal:

1. (a) The applicant’s full name;
2. (b) The applicant’s business name, address, and telephone number;
3. (c) The applicant’s home address and telephone number;
4. (d) The applicant’s e-mail address;
5. (e) The applicant’s license number and expiration date;
6. (f) The renewal amount due and late fee if applicable;
7. (g) Whether it’s a first time renewal;
8. (h) An attestation that the applicant has complied with the continuing education requirements of Geo 403;
9. (i) A statement indicating any disciplinary or legal judgments against the applicant for his or her services as a professional geologist;
10. (j) A statement indicating that the applicant has adhered to the ethical and professional standards of Geo 500;
11. (k) The applicant’s acknowledgement that knowingly providing the board with false information, or providing information with disregard for its truth or falsity when such information is in fact false, provides a basis for disciplinary action by the board; and
12. (l) The applicant’s signature and date.

Source. #7526, eff 7-1-01; ss by #9439, eff 3-25-09; ss by #12152, eff 3-24-17