Form 08-4430 - Application For Board Approved Professional Counselor Supervisor Page 2

Please give a statement that details your supervision philosophy, orientation, and experience.

I certify that I will adhere, and will continue to adhere, to the ethical guidelines adopted which are the Ethical

Guidelines for Counseling Supervisors of the Association for Counselor Education and Supervision (ACES),

American Counseling Association (ACA), 1993 edition (12 AAC 62.200 and 12 AAC 62.200(a)(3) and (b)).

I hereby certify that the information in this application is true and correct to the best of my knowledge.

WARNING: Alaska Statute 11.56.200 states that a person commits the crime of perjury if he/she makes a

false statement.

Signature of Applicant

SUBSCRIBED AND SWORN to before me, a Notary Public, in and for the State of

this _______ day of

, in the year of ________.

Notary Public

My Commission Expires:

08-4430 (New 12/00)

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Parent category: Legal