Application For Conditional Professional Counselor License Form 1998

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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

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