Form 08-4404 - Professional Counselor Application For Transitional Licensure (Page 2 of 3) in pdf

Form 08-4404 - Professional Counselor Application For Transitional Licensure Page 2

OCCUPATIONAL DATA – In chronological order, from most recent to most remote for the last five years, list all relevant

or related professional positions held. Provide name of employer, mailing address, phone number, position held, duties,

responsibilities, and name of direct supervisor(s).

6. Name of Employer:

Dates: From

Employer Address:

Employer Telephone Number:

Name of Supervisor(s):

Position held by Applicant:

Duties and Responsibilities:

Name of Employer:

Dates: From

Employer Address:

Employer Telephone Number:

Name of Supervisor(s):

Position held by Applicant:

Duties and Responsibilities:

Name of Employer:

Dates: From

Employer Address:

Employer Telephone Number:

Name of Supervisor(s):

Position held by Applicant:

Duties and Responsibilities:

Name of Employer:

Dates: From

Employer Address:

Employer Telephone Number:

Name of Supervisor(s):

Position held by Applicant:

Duties and Responsibilities:

Name of Employer:

Dates: From

Employer Address:

Employer Telephone Number:

Name of Supervisor(s):

Position held by Applicant:

Duties and Responsibilities:

08-4404 (Rev. 11/99)

OVER

Form 08-4404 - Professional Counselor Application For Transitional Licensure Page 2