Form 08-4403 - Professional Counselor Licensure Application
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3PCO
State of Alaska
FOR DEPARTMENT USE
License Number:
ONLY
Department of Community and Economic Development
Division of Occupational Licensing
Board of Professional Counselors
P.O. Box 110806, Juneau, Alaska 99811-0806
Issue Date:
Telephone: (907) 465-2551
E-mail: license@dced.state.ak.us
Expiration Date:
PROFESSIONAL COUNSELOR LICENSURE
APPLICATION
I HEREBY APPLY for licensure as a professional counselor by:
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Examination
Credentials
This application must be completed in full. If a section does not apply, write N/A in the space provided. Please print or
type.
1. Name:
Last
First
M.I.
Maiden
Social Security Number:
Date of Birth:
Sex:
(Required by AS 08.01.060)
2. Mailing Address:
Street or Box
City
State
Zip Code
Business Telephone No.:
Home Telephone No.:
EDUCATION: List name and mailing address of master’s and doctorate programs attended. Give dates of attendance
and graduation.
3. College (Master):
Date Degree Awarded:
Type of Degree:
4. College (Doctorate):
Date Degree Awarded:
Type of Degree:
PROFESSIONAL DATA
5. List state(s) where you currently hold or have held a license or certified to practice professional counseling,
psychology, marital and family therapy, or social work. Please indicate whether certified or licensed.
State
Date Issued
Expiration Date
Licensed/Certified
a.
b.
6. List any state(s) in which you passed/failed a professional counseling examination.
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a.
State:
Exam Date:
Pass
Fail
Exam Administered by:
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b..
State:
Exam Date:
Pass
Fail
Exam Administered by:
08-4403 (Rev. 11/99)
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