Request active - non renewal by request status form

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Primary License (MD, DO, L, RSV, SP) - Will also change the status of
                                                            Active ACSC.
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 INACTIVE.

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.


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