1. (a) The applicant shall report the hours on the “Continuing Education Audit Reporting” form provided by the board by April 1 of even-numbered years. Documentation of attendance shall be attached to the form. Such documentation shall include the name of the applicant, the title of the course, the number of hours of the course, and the date the course was taken.

2. (b) The applicant shall provide the following information on the “Continuing Education Audit Reporting Form”:

   1. (1) The applicant's name;
   2. (2) The applicant’s license number;
   3. (3) The applicant's home address;
   4. (4) The applicant's personal phone number;
   5. (5) The applicant's place of employment;
   6. (6) The applicant's address of employment;
   7. (7) The applicant's business phone;
   8. (8) The total number of podiatric continuing education hours obtained;
   9. (9) The total number of hours obtained for pain management, addiction disorders, or a combination of both as required by Pod 402.01(d); and

   10. (10) The applicant’s signature and date of signing below the following preprinted statement:

       “To the best of my knowledge and belief the information provided on the continuing education reporting form and supporting documentation are true, complete, and not misleading. I understand that any material misrepresentation shall be subject to disciplinary action by the board.”

Source. #8061, eff 3-12-04, EXPIRED: 3-12-12 New. #10242-B, eff 12-15-12