State Form 27522 - Application For License To Practice Psychology In Indiana

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APPLICATION FOR LICENSURE TO PRACTICE
Health Professions Bureau
PSYCHOLOGY IN INDIANA
FOR AGENCY USE ONLY:
PSYCHOLOGY LICENSE
TEMPORARY PERMIT
APPLICANT
month, day, year
month, day, year
month, day, year
month, day, year
DO NOT WRITE ABOVE THIS LINE
last, first, middle, maiden
number, street or Rural Route
daytime
month, day, year
GRADUATE EDUCATION (Doctoral)
excluding dissertation hours
PREDOCTORAL INTERNSHIP
number,street, city, state and ZIP code
months,days,years

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