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Form 08-4113a - Verification Of Licensure Form - Board Of Psychologist And Psychological Saaociate Examiners

STATE OF ALASKA

Board of Psychologist and Psychological Associate Examiners

VERIFICATION OF LICENSURE

Applicant: Some states require a fee for completion of license verification; you may wish to check with the state

board prior to submitting this form to them for completion:

State Board:

In applying for licensure to practice psychology in the State of Alaska, the Board of Psychologist and Psychological

Associate Examiners requires this form to be completed by the jurisdiction in which I hold a license or have held

licenses. Please complete this form and send it directly to:

Department of Community and Economic Development

Division of Occupational Licensing

Board of Psychologist and Psychological Associate Examiners

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-3811

E-mail: license@dced.state.ak.us

Signature:

Printed Name:

License No.:

Address:

PLEASE DO NOT DETACH

The information below must be completed by the State Licensing Board. It may not be completed by the applicant.

State of

Board of

Name of Licensee

Type of License Held

License No.

Issued Effective

License is Current

Lapsed

Expiration Date

By Reciprocity/Endorsement

By Examination

Date of Exam

Form

Percent Score

Raw Score

Examination Administered By

Licensee received at least

year(s) of supervised, post doctoral experience during the

period from

08-4113a (Rev. 6/00)

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Form 08-4113a - Verification Of Licensure Form - Board Of Psychologist And Psychological Saaociate Examiners