Form 08-4362 - Application For Licensure As A Psychological Associate

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PSY
Department of Community and Economic Development
For Department Use Only
Division of Occupational Licensing
Board of Psychologist and Psychological Associate Examiners
P.O. Box 110806
Juneau, Alaska 99811-0806
Telephone: (907) 465-3811
E-mail: license@dced.state.ak.us
APPLICATION FOR LICENSURE AS A PSYCHOLOGICAL ASSOCIATE
I HEREBY APPLY for licensure as a Psychological Associate
Temporary License Requested:
Yes
No
This application must be completed in full. If any section does not apply, write N/A in the space provided. PLEASE
PRINT OR TYPE.
Name:
Last
First
M.I.
Maiden
Mailing Address:
Street or Box
City
State
ZIP Code
Business Telephone:
Home Telephone:
Social Security Number:
Date of Birth:
Sex:
EDUCATION
List names, addresses, and ZIP codes of ALL undergraduate colleges and universities attended. Give dates of
attendance and graduation.
College (Baccalaureate)
List names, addresses, and ZIP codes of ALL Master’s and Doctorate universities attended. Give dates of
attendance and graduation.
College (Master’s)
Area of Emphasis:
Date Degree Earned:
08-4362 (Rev. 6/00)
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