Form 08-4404 - Professional Counselor Application For Transitional Licensure

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PCO
State of Alaska
FOR DEPARTMENT USE
License Number:
ONLY
Department of Community and Economic Development
Division of Occupational Licensing
Board of Professional Counselors
P.O. Box 110806, Juneau, Alaska 99811-0806
Issue Date:
Telephone: (907) 465-2551
E-mail: license@dced.state.ak.us
Expiration Date:
PROFESSIONAL COUNSELOR
APPLICATION FOR TRANSITIONAL LICENSURE
This application must be completed in full. If a section does not apply, write N/A in the space provided. Please print or
type. All supporting documents and fees required must be postmarked or received by the department by June 30, 2000.
1. Name:
Last
First
M.I.
Maiden
Social Security Number:
Date of Birth:
Sex:
(Required by AS 08.01.060)
2. Mailing Address:
Street or Box
City
State
Zip Code
Business Telephone No.
Home Telephone No.:
EDUCATION- List name and mailing address of Master’s or Doctorate programs attended. Give dates of attendance and
graduation.
3. College(Master):
Date Degree Awarded:
Type of Degree:
College(Doctorate):
Date Degree Awarded:
Type of Degree:
FOR INFORMATION ONLY
4. List the state(s) where you currently hold or have held a license or certification to practice professional counseling,
psychology, marital and family therapy, or social work.
State
Date Issued
Expiration Date
Licensed/Certified
a.
b.
c.
08-4404 (Rev. 11/99)
OVER

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