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Request For Re-Examination Form

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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 RE-EXAMINATION

To confirm receipt, mail this form using a method that includes tracking. Processing time will vary

depending on application volumes. A waiting period is required between retakes. See page 2 for

more information.

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. Exam Type:

LCSW Law and Ethics Exam

If you need to retake a Law and Ethics Exam,

you MAY be required to attach a certificate of



LMFT Law and Ethics Exam

completion for a 12-hour course on Law and



PICK ONLY

LPCC Law and Ethics Exam

Ethics. See below** for details.

ONE

LMFT Clinical Exam

LEP Exam

4. Legal Name:

Last

First

Middle

5. Address of Record***:

Number and Street

City

State

Zip Code

6. Is this a new address?

Yes

If YES, we will update our records accordingly

7. Business Telephone:

8. Residence Telephone:

9. E-Mail Address (OPTIONAL):

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

Number, or Individual Taxpayer Identification Number, as applicable.

** If you hold a current or delinquent intern or associate registration, and did not pass the Law

and Ethics Exam prior to your registration’s expiration date, you may be required to complete a

12-hour course on California Law and Ethics before you will be allowed to retake the exam. See

page 3 to determine whether you are required to attach proof of course completion.

*** The address you enter on this application is public information and will be placed on the

Internet pursuant to Business and Professions Code section 27. If you don’t want your home or

work address available to the public, use an alternate mailing address.

37A-298 (Revised 01/2017)

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Request For Re-Examination Form

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