Request For Initial Lmft California Clinical Examination printable pdf download

Request For Initial Lmft California Clinical Examination

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY

Governor Edmund G. Brown Jr.

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830 TTY: (800) 326-2297 FAX: (916) 574-8626

REQUEST FOR INITIAL

LMFT CALIFORNIA CLINICAL EXAMINATION

• This form and fee will ONLY be accepted from individuals whose “Application for LMFT

Licensure and Examination” and hours of experience have been approved by the Board,

AND who have also passed the LMFT California Law and Ethics Examination.

• To confirm receipt, mail this form using a method that includes tracking.

• Processing times will vary depending on application volumes.

For Office Use Only

$100 FEE MUST ACCOMPANY THIS FORM

Cashiering No

Make check payable to - Behavioral Sciences Fund

(Type or print clearly in ink)

1. SSN or ITIN*:

2. Registration Number:

3. Legal Name:

Last

First

Middle

4. Address of Record**:

Number and Street

City

State

Zip Code

5. Is this a new address?

Yes

If YES, we will update our records accordingly

6. Business Telephone:

7. Residence Telephone:

8. E-Mail Address (OPTIONAL):

NOTE: Knowingly providing false information or omitting pertinent information may be

grounds for denial of this application.

Signature of Applicant

Date

* You may provide either your Social Security Number, your Federal Employer Identification

Number, or Individual Taxpayer Identification Number, as applicable.

37A-299 (Revised 01/2017)

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Request For Initial Lmft California Clinical Examination