Form 08-4203 - Marital And Family Therapist License Application - 2000
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4MFT
FOR DEPARTMENT USE
License Number
State of Alaska
ONLY
Department of Community and Economic
Development
Division of Occupational Licensing
Issue Date
Board of Marital and Family Therapy
P.O. Box 110806, Juneau, Alaska 99811-0806
Telephone: (907) 465-2551
E-mail: license@dced.state.ak.us
Expiration Date
MARITAL AND FAMILY THERAPIST
LICENSE APPLICATION
Credentials
Examination
Temporary License
(for exam applicants only)
This application must be completed in full. If a section does not apply, write N/A in the space provided. Please print or type.
Name:
Last
First
M.I.
Maiden
Social Security Number:
Date of Birth:
Sex:
(Required by AS 08.01.060)
Mailing Address:
Street or P.O. Box
City
State
Zip Code
Business Telephone:
Home Telephone:
EDUCATION:
List names, addresses, and zip codes of ALL Masters and Doctorate programs attended. Give dates of attendance and
graduation.
College (Master):
Title of Degree:
Date degree awarded:
College (Doctorate):
Title of Degree:
Date degree awarded:
FOR BOARD INFORMATION ONLY:
Please list any national professional organizations in which you hold current membership:
1.
2.
3.
08-4203 (Rev. 4/00)
OVER
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Parent category: Legal