Report Or Request Of Court Authorized Examiner Regarding Licensing Change {EXAM 4}

IN THE CIRCUIT COURT OF IN RE: [Name of Licensed Independent Clinical Social Worker, Advanced Nurse Practitioner with Psychiatric Certification, or Physician Assistant] Address: COUNTY, WEST VIRGINIA Case No.: Phone #: -P- City: State: Zip: REPORT/REQUEST OF COURT AUTHORIZED EXAMINER REGARDING LICENSING OR CERTIFICATION CHANGE [W. Va. Code: §27-5-2(e)] On this day of [month], [year], comes the above named ) Licensed Independent Clinical Social Worker (WV SW License #: and/or Advanced Nurse Practitioner with Psychiatric Certification (WV RN License #: ) and/or Physician Assistant (WV License #: ) and advises the Court per prior Order of the following: [check applicable item(s)] Examiner's license is no longer in good standing with the West Virginia Board of Social Work Examiners. Examiner's license and/or certification is no longer in good standing with the West Virginia Board of Examiners for Registered Professional Nurses. Examiner's certification as a from the agency, , is no longer in good standing. Examiner's license is no longer in good standing with the West Virginia Board of Medicine. Examiner's license is no longer in good standing with the West Virginia Board of Osteopathy. Examiner reports the following additional certifications/licenses: [describe/name and provide certification/licensee number(s) and expiration dates] EXAM 4 Rev. 11/2013 Report American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 Examiner became subject to the following disciplinary action related to his/her license: [add additional pages if needed] Examiner requests [check appropriate box] continuation discontinuation removal of limitation of authorization to perform examinations for probable cause proceedings for involuntary hospitalization. Examiner submits the following additional information for the Court's consideration: [add additional pages as needed] VERIFICATION I, , Examiner/Petitioner, after making an oath or affirmation to tell the truth, certify, UNDER PENALTIES OF FALSE SWEARING as provided by law, that the information and statements contained in this Report and any additional pages added hereto are true and accurate to the best of my knowledge, information and belief, that any and all attached copies are true and accurate copies of the originals. I understand that if I knowingly provide FALSE information, I could be subject to a criminal charge of false swearing. Date Signature The foregoing was sworn to or affirmed before me on the [month], [year]. day of Notary Public My commission expires: EXAM 4 Rev. 11/2013 Report American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 CONTINUATION SHEET Use this sheet to enter information that would not fit in the space(s) provided above. Label each response EXAM 4 Rev. 11/2013 Report American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3