Experience Supervision Form Page 2

SECTION B

Must be completed by supervisor

By signing below, I hereby attest that:

 The applicant completed the experience as specified in this policy document under my supervision and

in compliance with all of the stated requirements.

 I am the responsible supervisor designated in the supervision contract with this supervisee.

 During the applicant’s experience I was a Board Certified Behavior Analyst #

Supervisor: By signing below, you attest that ALL of the information contained on this

Experience Verification Form is true and correct to the best of your knowledge.

Printed Name of Supervisor:

Signature:

Date:

This document must bear the original signature of the supervisor. Photocopies, faxed, or emailed copies of this

document will not be accepted. Original documents that have been altered (white-out, strike-through, etc.) will not be

accepted. Incomplete documents will not be accepted.

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