Form 08-4404 - Professional Counselor Application For Transitional Licensure Page 3
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3PROFESSIONAL FITNESS
The following questions must be answered. “Yes” answers may not automatically result in license denial.
YES
NO
1.
Have you ever been disciplined by any state board for any violation of the Professional
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Counselor Practice Act or unethical conduct? ....................................................................................
2.
Have you ever had a license to practice professional counseling, psychology, marital
and family therapy, social work, or applied behavioral science revoked, suspended,
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restricted or limited? ...........................................................................................................................
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3.
Have you ever had any malpractice settlements or judgements paid on your behalf? ......................
4.
Have you ever been convicted of a violation of a federal or state statute or Canadian
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law? ....................................................................................................................................................
5.
Are you now or within the past five years been convicted of driving under the influence
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of alcohol, drugs, or chemical substances? .......................................................................................
6.
Are you now or within the past five years been addicted to or excessively used or misused
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alcohol, narcotics, barbiturates, or habit-forming drugs? ...................................................................
7.
Are you now or within the past five years been treated for/or hospitalized for emotional or
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mental illness, drug addiction, or alcoholism? ....................................................................................
If you answered “Yes” to any of the above questions, please explain dates and circumstances on a separate piece of
paper, and send any supporting documents that are applicable (court records, etc.).
Please be advised that all information provided with this application will be available to the public unless required to be
kept confidential by state or federal law.
I hereby certify that the information in this application is true and correct to the best of my knowledge. I understand that
any false information may result in failure to obtain licensure as a professional counselor in Alaska, or subsequent
revocation of my license.
Signature of Applicant
SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of
this
day of
, in the year of
.
Notary Public
My Commission Expires______________
WARNING:
The Board of Professional Counselors may deny, suspend, or revoke the license of a person who has
obtained or attempted to obtain a license to practice professional counseling by fraud or deceit. The person may also be
subject to criminal charges for perjury or unsworn falsification. (AS 11.56.210 and AS 11.56.230)
08-4404 (Rev. 11/99)
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