ACKNOWLEDGEMENT OF RESPONSIBILITY TO

    MAINTAIN CURRENT LICENSE, CERTIFICATION OF REGISTRATION

    NAME:_____________________________________________________________________

    JOB TITLE:___________________________________________________________________

    TYPE OF REQUIRED LICENSE/CERTIFICATE/REGISTRATION:______________________

    ___________________________________________________________________________

    EXPIRATION DATE:__________________________________________________________

    I understand that it is my responsibility to obtain and maintain a current license, certificate or

    registration when necessary or appropriate. I understand that I am to advise my supervisor or

    Human Resources office of any problem encountered regarding my license, certificate or

    registration. I further understand that FAILURE to maintain a current license, certificate or

    registration will result in separation from employment.

    _____________________________

    Signature of Employee

    _____________________________

    Date