1. Every person licensed under the provisions of this chapter shall renew his certificate of registration on or before the registration renewal date. The application shall be made under oath on a form furnished by the board. The application shall include, but not be limited to, disclosure of the following: the applicant’s full name and his office and residence address and the date and number of his license; all final disciplinary actions taken against the applicant by any professional medical or osteopathic association or society, licensed hospital or medical staff of the hospital, state, territory federal agency or country; and, information concerning the applicant’s current physical and mental fitness to practice as a physician and surgeon.

2. A blank form for application for registration shall be mailed to each person licensed in this state at his last known office or residence address. The failure to receive it does not, however, relieve any person of the duty to register and pay the fee required by the chapter nor exempt him from the penalties provided by this chapter for failure to register.

3. If a person licensed, certified, or registered by the board of healing arts does not renew such license, certification, or registration for two consecutive renewal periods, such license, certification, or registration shall be deemed void.