Missouri Revised Statutes Title XXII. Occupations and Professions § 340.316. Application, contents--false statements, penalty

(1) Applicant's full name;

(2) Place of employment;

(3) Supervisor's name, license number and signature;

(4) Business and residence addresses;

(5) Date and number of applicant's certificate;

(6) Any disciplinary actions taken against the applicant by any state, territory or district of the United States or federal agency;

(7) Felony criminal convictions;

(8) Continuing educational credits; and

(9) Other information deemed necessary by the board to assess the applicant's fitness for certificate renewal.