APPLICATION FOR LICENSURE TO PRACTICE
Health Professions Bureau
PSYCHOLOGY IN INDIANA
FOR AGENCY USE ONLY:
PSYCHOLOGY LICENSE
TEMPORARY PERMIT
APPLICANT
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month, day, year
month, day, year
month, day, year
DO NOT WRITE ABOVE THIS LINE
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number, street or Rural Route
daytime
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GRADUATE EDUCATION (Doctoral)
excluding dissertation hours
PREDOCTORAL INTERNSHIP
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