Request active non renewal status form
* indicates a required field
Licensee name: *
License number: *
Your email address: *
Confirm your email address: *
Telephone number: *
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. With this status the licensee will not receive any renewal notices and after annual renewals the license status will become INACTIVE.
This form uses Huggins' Email Form Script