2015 LBA Renewal - Louisiana Behavior Analyst Board

Louisiana Behavior Analyst Board
2015 Licensed Behavior Analyst Renewal Notice
Your current license expires December 31, 2014.
1. Review and complete Sections I and II of the 2015 Licensed Behavior Analyst Renewal
Form. Update all new contact information. Renewal Application is not valid without
behavior analyst’s initials.
2. Return this renewal application, along with the current renewal fee of $400 in the form of a
certified check or money order only to: LBAB, 8706 Jefferson Highway, Suite B, Baton
Rouge, LA 70809.
3. Renewals may require 1-2 weeks to process. Please submit information in a timely fashion.
1. Noncompliance includes, in part, incomplete forms, unsigned forms, failure to file all of the
required renewal forms by December 31st, or failure to postmark the renewal package by
December 31st.
2. If your license is not renewed by the end of December, the license will be regarded as
lapsed effective January 1st. An individual shall not practice applied behavior analysis in
Louisiana while the license is lapsed.
3. If your license lapses, all of your line technicians must immediately cease and desist all work
with clients.
4. A lapsed license may be reinstated, at the approval of the Board, if all applicable
requirements have been met, along with payment of the renewal fee and a late filing fee.
Continuing Education:
1. Please note that continuing education hours do not need to be reported for the 2014 and
2015 reporting periods.
2. For the reporting period of January 2015-December 2016 and henceforth, 32 credits of
continuing professional development will be required in the biennial reporting period for
Licensed Behavior Analysts.
3. Continuing education rules will be available on www.lababoard.org in early 2015. We urge
you to review the rules and regulations and begin completing your continuing education
requirement in 2015 for the 2016 reporting period.
2015 Licensed Behavior Analyst Renewal Form
Your Current License Expires December 31, 2014
Annual Renewal Fee: $400
(Certified checks or money orders only)
License# Date Licensed
Please indicate your preferred mailing address by checking same below. Please note, your
work address is public information.
Work Address [ ]Preferred Mailing
Work Phone
E-mail [required]
Home Address [ ] Preferred Mailing
Fax Phone
Cell Phone
Home Phone
Since your initial licensure date have you been disciplined by any professional licensing
board, in any state; or, arrested, charged, convicted of, or entered a plea of guilty, nolo
contendere, or no contest to, a crime in any jurisdiction, including a military court martial,
other than a minor traffic offense? (You must include all misdemeanors and felonies, even
if adjudication was withheld by the court so that you would not have a record of conviction.
Driving under the influence or driving while impaired is not a minor traffic offense for the
purposes of this question.) If you check "Yes", attach a detailed explanation and relevant
documentation which includes date(s), location(s), specific circumstances, practitioners
and/or treatment involved, etc.
Licensed Behavior Analyst Initials:_______
Each renewal application is processed in the order it is received. Please submit your renewal no later
than December 15, 2014 to avoid delay in receiving 2015 Renewal Certificate.