Each certificate holder, affected by the continuing education requirements of this chapter, is responsible for filing with the superintendent of public instruction, before the expiration date, an application form supplied by the superintendent of public instruction, which indicates compliance with the continuing education requirements of this chapter. Such form shall:

(1) Provide space for indicating how the certificate holder met the continuing education requirement.

(2) Include an attestment by the certificate holder as to the accuracy of the information provided.

(3) State thereon that falsification or deliberate misrepresentation, including omission, of any material fact shall be an act of unprofessional conduct for which the holder's certificate may be revoked.