An applicant for certificate renewal shall provide to the Board a signed statement, under penalty of perjury, on an appropriate form supplied by the Board, setting forth the following minimum information for qualification: Name of the qualified sponsor; Location of the approved continuing education course; Title and description of the approved continuing education course; Dates attended; Number of hours claimed; and Other information the Board considers appropriate. The Board, at the Board's discretion, may verify the information submitted by a certificate holder. The certificate holder shall be responsible for maintaining records used to support credits claimed. The records shall be maintained by certificate holders for a period of at least 2 years from the date of completion of the approved continuing education course.