Form 08-4362 - Application For Licensure As A Psychological Associate (Page 2 of 4) in pdf

Form 08-4362 - Application For Licensure As A Psychological Associate Page 2

PROFESSIONAL DATA

List the state(s) in which you are and have been certified or licensed to practice psychology:

State:

License No.

Issue Date:

Expiration Date:

State:

License No.

Issue Date:

Expiration Date:

State:

License No.

Issue Date:

Expiration Date:

List any state(s) in which you took a psychology licensing examination:

Circle either Passed

Failed, as appropriate

State:

Exam Date:

Passed

Failed

State:

Exam Date:

Passed

Failed

State:

Exam Date:

Passed

Failed

Are you a diplomate in good standing of the American Board of Professional Psychology?

Yes

OCCUPATIONAL DATA: In chronological order, from most recent to most remote, list all relevant or related

professional positions held. Provide names of employers, addresses, ZIP codes, telephone numbers, positions

held, duties and responsibilities, and name of direct supervisor(s):

1. Name of Employer:

Dates: From:

To:

Employer Address:

Employer Telephone Number:

Name of Supervisor:

Position Held by Applicant:

Duties and Responsibilities:

2. Name of Employer:

Dates: From:

To:

Employer Address:

Employer Telephone Number:

Name of Supervisor:

Position Held by Applicant:

Duties and Responsibilities:

08-4362 (Rev. 6/00)

Form 08-4362 - Application For Licensure As A Psychological Associate Page 2

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