Obladc Form 205 Oklahoma Board Of Licensed Alcohol/drug Counselors - Professional Reference Form

ADVERTISEMENT

OKLAHOMA BOARD OF LICENSED ALCOHOL/DRUG COUNSELORS
P O Box 54388
Oklahoma City, OK 73154-0388
PROFESSIONAL REFERENCE FORM
________________________
___CONFIDENTIAL___
Dear ________________________________
I am applying to the OKLAHOMA LICENSURE BOARD for ALCOHOL AND DRUG
COUNSELORS for licensure/certification as a
LADC
CADC counselor. Three
professional references must be included as part of the application process. Would you please
complete the reference material below for me? I have authorized the Licensure Board to request
additional information from you if necessary. Your prompt attention to this would be very much
appreciated, as my application will not be processed until the Board receives this
recommendation .
Sincerely,
_______________________________________
Signature of applicant
NOTE FROM THE LICENSURE BOARD
The Licensure Board believes that license/certification should be based on input from a variety
of sources including the observations of persons who have known the applicant professionally.
For this reason, all applicants are required to list three references who will complete the
Professional Reference Form below. Your evaluation plus that received from other references
and the data furnished by the applicant will be used in determining eligibility for
licensure/certification. The process can only be as good as you and others make it by careful and
truthful reporting.
PLEASE RETURN THE COMPLETED EVALUATION FORM TO THE PERSON REQUESTING IT
To be completed by Applicant
Applicant’s Name: _____________________________________________________________________
Applicant’s Address: ___________________________________________________________________
City
State
Zip
Applicant’s Place of Employment: _________________________________________________________
Applicant’s Telephone Number: _(_______)_________________________(______ )_________________
Work phone
Home phone
OBLADC Form 205
8/2005
1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2