1. The application shall include the disclosure of:
(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.
2. The application shall be made under oath or affirmation by the applicant. The applicant is subject to penalties provided for under the laws of this state for making a false statement under an oath or affirmation, which shall be in addition to and not in lieu of any penalty or other discipline provided for by sections 340.200 to 340.330.