Form 08-4113 - Application For Licensure As A Psychologist

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PSY
State of Alaska
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
Telephone: (907) 465-3811
E-mail: license@dced.state.ak.us
APPLICATION FOR LICENSURE AS A PSYCHOLOGIST
I APPLY for licensure as a Psychologist
By:
Credentials
Examination
This application must be completed in full. If any section does not apply, write N/A in the space provided. PLEASE
PRINT OR TYPE.
Name:
Last
First
M.I.
Maiden
Mailing Address:
Street or Box
City
State
ZIP Code
Business Telephone:
Home Telephone:
Social Security Number:
Date of Birth:
Sex:
EDUCATION
List names, addresses, and ZIP codes of ALL undergraduate colleges and universities attended. Give dates of
attendance and graduation.
College (Baccalaureate)
List names, addresses, and ZIP codes of ALL Masters and Doctorate universities attended. Give dates of
attendance and graduation.
College (Masters)
College (Doctorate)
Doctoral Thesis:
Area of Emphasis:
Title of Thesis:
Date Degree Earned:
08-4113 (Rev. 6/00)
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