Application For Psychology License Form - Bureau Of Occupational Licenses, State Of Idaho
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4IDAHO STATE BOARD OF PSYCHOLOGY
BUREAU OF OCCUPATIONAL LICENSES
1109 Main Street, Suite 220
Boise, Idaho 83702-5642
(208) 334-3233
csimpson@ibol.state.id.us
APPLICATION FOR PSYCHOLOGY LICENSE
A $200.00 application fee & either a $400.00 examination fee or a $100.00 endorsement fee must accompany this application.
I hereby submit my qualifications and make application for a Psychology license in the State of Idaho under the provisions of Title 54,
Chapter 23, Idaho Code, and provide the following:
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 Doctorate degree from ________________________________ on _____________ with Major in ________________
You must document either a doctoral degree in Psychology OR a doctoral degree in a field related to Psychology, which meets
the requirements outlined under Rule 500, and complete Addendum 1. Official university/college transcripts must be received by
this office directly from the school registrar.
8. List the department of the university/college awarding the degree noted in item 7. __________________________________
9. List the title of the degree program (e.g. Clinical Psychology; Counseling Psychology; etc.) ____________________________
10. Was the program approved by the A.P.A. at the time the degree was awarded?
[ ]Yes
[ ]No
11. Who was your major advisor for the doctoral program? ________________________________________________________
12. What was the title of your dissertation? ______________________________________________________________________
13. Please list the name and address of your primary internship supervisor below: (Internship does not count toward #14 below.)
________________________________________________________________________________________________________
14. At least two (2) years (2000 hours minimum) of documented supervised experience, one (1) year (1000 hours minimum) of
which must be post-doctoral is required for Idaho licensure. Please list the names and addresses of all supervisors below:
_________________________ _________________________ _________________________
name
name
name
_________________________ _________________________ _________________________
position & psychology license number
position & psychology license number
position & psychology license number
_________________________ _________________________ _________________________
current address
current address
current address
_________________________ _________________________ _________________________
city, state, zip
city, state, zip
city, state, zip
(continued)
BOL – PSY-1 - revised 05/24/99
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