Application For Conditional Professional Counselor License Form 1998 printable pdf download

STATE OF IDAHO

BUREAU OF OCCUPATIONAL LICENSES

1109 Main Street, Suite 220

Boise, Idaho 83702-5642

APPLICATION FOR CONDITIONAL PROFESSIONAL COUNSELOR LICENSE

An application fee of $75.00 and a license fee of $75.00 must be submitted with this application.

I hereby make application for a conditional license as a professional counselor in the state of Idaho under the provisions of Title 54,

Chapter 34, Idaho Code, and provide the following:

1. Full Name (Mr., Mrs., or Ms.) _______________________________________________________________________________

2. Mailing address___________________________________________________________________________________________

Street/PO Box

City

State

Zip

3. Date of Birth _______/_______/_______ Place of Birth_____________________ Social Security No. ______/______/______

month

day

year

4. Home phone number _(____)________________

Business phone number _(____)_______________

5. Are you currently or have you ever been licensed in another state?

[ ]Yes

[ ]No

(If yes, please attach documentation certifying said licensure and current status.)

6. Have you ever had a license, certification, or registration revoked or suspended?

[ ]Yes

[ ]No

(If yes, please attach a detailed statement, including a copy of the charges and the final order.)

7. Have you ever been convicted of any State or Federal felony?

[ ]Yes

[ ]No

(If yes, please attach a detailed statement, including a summary of the charges, the final order, any probation or parole

documentation, and any other relevant information.)

8. Do you have three (3) or more years of established counselor practice?

[ ]Yes

[ ]No

(If yes, please provide documentation of said practice including: business name(s), employer(s)/supervisor(s) name(s), address(es),

and dates of practice.)

9. You must have a degree in a counseling field from an accredited university/college.

[ ] BS [ ] MS [ ] Ph.D.

(Please provide certified transcripts documenting the counseling emphasis of the course work.)

10. Attach an un-mounted passport style photograph of yourself, taken within 30 days of this application.

I hereby certify that the responses provided above are true and accurate to the best of my knowledge and belief and that all

documentation attached is true and accurate. I hereby agree to follow the ethical standards of a Licensed Professional Counselor and

acknowledge that my failure to meet all requirements for licensure as a professional counselor prior to December 31, 2001 will result

in the expiration of my conditional license.

I hereby authorize and direct any person, agency, firm, or other entity to release, upon the request of the Bureau of Occupational

Licenses or it’s authorized representative, any information, communication, report, record, statement, recommendation, or disclosure

that may have bearing on my eligibility for or maintenance of the license for which I am applying. I understand that by signing this

form I am authorizing the release of information about me that may otherwise be protected or confidential.

I hereby waive access to any and all third party professional references, evaluations, or reports that may be submitted concerning my

application or licensure.

_____________________________________________________

Signature of applicant

State of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 19 _____.

______________________________________________________

(seal)

Notary Public official signature

residing at_____________________________________________

my commission expires___________________________________

BOL-TEMP COND COU 07/08/98

Application For Conditional Professional Counselor License Form 1998

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