Application For Social Work License Form - Bureau Of Occupational Licenses, State Of Idaho
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3IDAHO STATE BOARD OF SOCIAL WORK EXAMINERS
BUREAU OF OCCUPATIONAL LICENSES
1109 Main Street, Suite 220
Boise, Idaho 83702-5642
(208) 334-3233
mlondon@ibol.state.id.us
APPLICATION FOR SOCIAL WORK LICENSE
An application fee of $40.00 ($45.00 for endorsement) must accompany this application.
I hereby submit my qualifications and make application for a: (please check applicable box)
[ ] Social Worker
[ ] Certified Social Worker
[ ] Private & Independent Practice
[ ] Clinical Practice
license to practice in the State of Idaho under the provisions of Title 54, Chapter 32, Idaho Code as amended.
1.
Full Name (Mr., Mrs., or Ms.) _______________________________________________________________________________
2.
Mailing address__________________________________________________________________________________________
Street/PO Box
City
State
Zip
3.
Date of Birth _______/_______/_______ Place of Birth___________________ Social Security No. ______/______/______
month
day
year
(Proof of age must be attached. A copy of your birth certificate, passport, military ID, or valid driver’s license is acceptable.)
4.
Daytime phone _(____)________________ Fax _(____)________________
E-mail _______________________________
5.
Attained Baccalaureate degree from ____________________________ on _____________ with Major in ________________
6.
Attained Masters degree from _________________________________ on _____________ with Major in _________________
7.
Attained Doctoral degree from _________________________________ on _____________ with Major in ________________
(Official college transcripts must be received by this office directly from the school registrar before your application will be processed.
If you have not yet received the required degree, but will within the next 2 quarters, ADDENDUM 1. must be completed.)
8.
Are you currently or have you ever been licensed in this or any other state?
[ ]Yes
[ ]No
(If Yes, official certification of licensure must be received by this office directly from the issuing authority before your application
will be processed. If previously licensed in Idaho, enter your license number here ___________________________
9.
Have you ever had a license, certification, or registration revoked, suspended or otherwise sanctioned?
[ ]Yes
[ ]No
(“Sanction” includes any voluntary or involuntary action that limits, restricts, or attaches conditions to lawful professional practice.
If Yes, a copy of the charges and the final order must be received before your application will be processed.)
10. Have you ever been convicted of any felony or offense involving moral turpitude?
[ ]Yes
[ ]No
(If Yes, a detailed statement, a summary of the charges, the final order, any probation or parole documentation, and any other relevant
information must be received before your application will be processed.)
11. Please attach the names and current addresses of three (3) persons, one (1) of which must be licensed in a health related
profession, willing to provide references regarding your character, training, and experience. (This office will send the required
forms, and must receive the completed letter(s) of reference before your application will be processed. If you have not yet graduated,
your references must include your faculty advisor and your field supervisor.)
_________________________ _________________________ _________________________
name
name
name
_________________________ _________________________ _________________________
position & license number
position & license number
position & license number
_________________________ _________________________ _________________________
current address
current address
current address
_________________________ _________________________ _________________________
city, state, zip
city, state, zip
city, state, zip
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BOL – SWO-1 - 12/00
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