STATE OF CALIFORNIA – DEPARTMENT OF CONSUMER AFFAIRS – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY GAVIN NEWSOM, GOVERNOR
1747 N. Market Blvd., Suite 180
Sacramento, CA 95834
P
916.515.5200
F
916.928.2204
www.acupuncture.ca.gov
ACUPUNCTURE LICENSE RENEWAL APPLICATION
$500.00
(non-refundable)
Mail the completed application and check, or money order, for $500 to the address above.
Renewals cannot b
e processed more than 60 days prior to a licensee’s expiration date.
Renewa
ls postmarked after the license expiration date will be assessed a $150 delinquent fee.
NAME (Last) (First) (Middle)
CONTINUING EDUCATION (CE) REQUIREMENT – Select one of the following:
I have complied with the CE requirements (50 hours every 2 years after the initial license period).
Pursuant to the Governor’s Executive Order N-39-20, acupuncture licensees expiring between March 31, 2020, and
October 31, 2021 are afforded additional time to comply with the Board’s continuing education requirements.
I have not completed the Board’s continuing education requirements and attest that I will complete the required CE
units on or before March 28, 2022.
I am on inactive status. (
ONLY mark this box if you have already received approval from the Board)
DISCIPLINARY QUESTIONS
Since you last applied for renewal, have you been convicted of any violation of the law of this or any other state,
the U.S, or other country, omitting traffic infractions under $300 not involving alcohol, dangerous drugs (as defined
in Section 4022 of the Code), or controlled substances.
Yes
No
Since you last renewed your license, have you been denied a license or had a license disciplined by another
licensing authority of this state, of another state, of any agency of the federal government, or of another country?
Yes
No
WALL LICENSE RENEWAL
I currently do not have a place of practice (in California).
If you do have a Wall License issued for a place of practice, all Wall Licenses must be renewed at the time of license
renewal by using the Board’s online renewal services or print and provide the Wall License Location form for each place of
pracitce that can be found at www.acupuncture.ca.gov
under Licensing Forms. This form can also be used for initial Wall
License applications as well as Wall License maintenance, including cancelations and replacements.
ATTESTATION
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Licensee Signature: ______________________________________________________ Date: _________________________
FOR BOARD USE ONLY
AMOUNT $ ___________________ RECPT # __________________________ DATE _________________________ ID # __________________________
License Renewal Application - rev 2021-10
