State Form 27522 - Application For License To Practice Psychology In Indiana Page 2
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2
3
4POST DOCTORAL EDUCATION
POST DOCTORAL INTERNSHIP / FELLOWSHIP
(number, street, city, state and ZIP code)
(months, days, years)
PROFESSIONAL IDENTITY BASED UPON DOCTORAL TRAINING
(Check only one or attach explanation)
specify
CLAIMED AREAS OF COMPETENCE
List all states, including Indiana, in which you have been licensed to practice any regulated health occupation:
DATE ISSUED
TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR PERMIT
STATE
NUMBER
CURRENT STATUS
(month,year)
(state, country)
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