Request active - non renewal by request status form
* indicates a required field
Licensee name: *
License number: *
Your email address: *
Confirm your email address: *
Telephone number: *
Which license type?: * (Select One)
Primary License (MD, DO, L, RSV, SP) - Will also change the status of
ACSC/QACSC License(s) Only
PA/AA License - Will also change the status of Active QACSC(s)
By submitting this request you acknowledge that you agree and understand that you are requesting the status of your license be changed from
ACTIVE to ACTIVE - NON RENEWAL BY REQUEST. With this status the licensee will not receive any renewal notices and after annual renewals the license status will become
If at a later time you decided you want the license returned to Active status you will have to reinstate the license.
Click Here for more information on reinstatement.
uses Huggins' Email Form Script