Form 1swpr - Application For Licensed Clinical Social Worker November 2015
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1
2Department Use Only
The University of the State of New York
Licensed Clinical Social
THE STATE EDUCATION DEPARTMENT
Worker Psychotherapy
Office of the Professions
Division of Professional Licensing Services
“R” Privilege
Form 1SWPR
Application for Licensed Clinical Social Worker
73 $100
PS
1
Psychotherapy “R” Privilege
Date Approved
Initials
2
1.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
6
6.
Telephone/E-Mail Address
Daytime phone
3
2. Birth Date
Month
Day
Year
Home or Business
4
3.
Print Name
Area Code
Phone
E-mail Address
(please print clearly)
Last
Home or Business
First
Middle
Licensee business address, phone and e-mail address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Mailing Address: Home or Business
5.
5
(You must notify the Department promptly of any address or name changes.)
6.
7
New York State DMV ID Number
(Driver or Non-Driver ID)
Line 1
Line 2
(Leave this blank if you do not have a New
York State DMV ID Number)
Line 3
City
State
Zip Code
Country/
Province
8
New York State Licensed Clinical Social Worker License Number: __________________________
9
Date of award of Graduate Social Work Degree: ________ / ________ / ________
mo.
day
yr.
10
Give any other names by which you have been known: ________________________________________________________________
Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 1SWPR, Page 1 of 2, Rev. 11/15
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