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Page 15 of 15 R39 Rev. 08/2012CERTIFICATION Be it known that the foregoing are (check all that apply)Regulations(check one)AdoptedEmergency RegulationsAmended as hereinabove statedRepealedby the aforesaid
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Attach any supporting documents or evidence required as specified in the instructions.
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Submit the completed form along with any required fees to the licensing authority.
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The suspension or revocation of licenses.
License holders.
You can fill out the form online or by mail.
To report any license suspensions or revocations.
Details about the suspension or revocation, license number, date, and reason.
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