Form 08-4430 - Application For Board Approved Professional Counselor Supervisor
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1
2STATE OF ALASKA
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
BOARD OF PROFESSIONAL COUNSELORS
P.O. BOX 110806
JUNEAU, AK 99811-0806
TELEPHONE: (907) 465-2551
E-mail: license@dced.state.ak.us
APPLICATION FOR BOARD APPROVED
PROFESSIONAL COUNSELOR SUPERVISOR
This application must be completed in full. If a section does not apply, write N/A in the space provided.
Please print or type.
1.
Name:
Last
First
Middle
Maiden
Social Security Number:
Date of Birth:
(Required by AS 08.01.060)
2.
Mailing Address:
Street or P.O. Box
City
State
Zip Code
Business Telephone:
Home Telephone:
PROFESSIONAL DATA
3.
List the state(s) where you currently hold or have held a license or certified to practice professional
counseling, clinical social work, marital and family therapy, psychology as a psychologist or
psychological associate, physician, or advanced nurse practitioner who is certified to provide
psychiatric or mental health services. Please indicate whether certified or licensed.
State
Date Issued
Expiration Date
Licensed/Certified
a.
b.
4.
I,
, am attesting that I have a
license to practice
.
License Number:
Date Issued:
Expiration Date:
State:
AND
practiced
for at least five years for the period of
to
.
08-4430 (New 12/00)
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