Clinical Social Worker Experience Verification Form Page 2
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1
2APPLICANT NAME: __________________________________________ ASW#: ________________
SUPERVISOR INFORMATION
Supervisor’s Name:
Business Telephone
License Type
License Number
State
Date First Licensed
1. If a physician, were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the
entire period of supervision?
Yes
No
If YES, provide certificate number:_________________
2. Were you employed by the supervisee’s employer? Yes
No
If NO, attach a copy of the letter of
agreement between you and the supervisee’s employer.
NOTE: Knowingly providing false information or omitting pertinent information may be grounds for
denial of the application. The Board may take disciplinary action on a licensee who helps an applicant
obtain a license by fraud, deceit or misrepresentation.
Signature of Supervisor: ________________________________________
Date: __________________
37A-201 (Rev. 04/2015)
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