Form 6a - Graduate Degree Information printable pdf download

Form 6a - Graduate Degree Information

Oregon Board of Licensed Professional Counselors and Therapists

Application for Licensure – Professional Counselor and/or Marriage & Family Therapist

Form #6A: Graduate Degree Information

Applicant’s name

Degree Program

Date admitted to degree program

Date degree issued

College/University Name

I. THE INSTITUTION:

Name of national or regional accreditation body granting full graduate level accreditation

during the time of applicant’s graduate program.

____________________________________________________

Year first accredited: ______________

II. THE DEGREE PROGRAM:

Name of degree awarded to the license applicant.

ATTACHMENT #1

Please provide a copy of the relevant pages in the college catalog that describe the course of

study and description of classes under which the applicant’s degree was conferred.

Required minimum full-time enrollment: # _______

Quarters

Semesters

Required # of credits for graduation _________

Quarters

Semesters

The number of practicum/internship clock hours required for graduation

__________________

The number of clock hours this student accrued in a practicum/internship __________________

As a graduate school representative, I certify that I have reviewed the information on this form

and that it is correct to the best of my knowledge.

_______________________________________________

__________________________________________

Name

Title

_________________________

________________________________________________________________

Phone Number

Address

__________________________________________________

___________________________________

Signature

Date

Form 6a - Graduate Degree Information