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For the Board of Professional Counselors to have sufficient information to assess the applicant’s qualifications, please

answer the following questions:

YES

To your knowledge, is the applicant of good moral character?.................................................................

To your knowledge, is the applicant currently or within the past five years been addicted

to or excessively used alcohol, narcotics, barbiturates, or habit-forming drugs? .....................................

To your knowledge, has the applicant ever been disciplined or sanctioned by another

state or jurisdiction? ..................................................................................................................................

To your knowledge, has the applicant violated the ethical standards for providers

of professional counseling, psychology, marital and family therapy, or social work

as established by another state agency or jurisdiction?............................................................................

To your knowledge, has the applicant misrepresented his or her qualifications to

the board in any way? ...............................................................................................................................

To your knowledge, has the applicant been sanctioned for practicing professional

counseling, psychology, marital and family therapy, or social services without a license? ........................

Would you evaluate the applicant’s technical knowledge and practical experience to be

Excellent

Very Good

Fair

Needs Improvement

Would you recommend this person for licensure as a professional counselor? .........................................

Any further comments the board might consider in reviewing this applicant:

I hereby certify that this information is true and complete to the best of my knowledge.

Check as appropriate

Signature:

I have been approved and certified as an

Printed Name:

approved supervisor by the Board of Professional

Counselors on

and

License Type:

I am a

License Number:

Licensed Professional Counselor

Licensed Clinical Social Worker

Institutional/Clinic Where Employed:

Licensed Marital and Family Therapy

Licensed Psychologist

Address:

Licensed Psychological Associate

Licensed Physician

Licensed Psychiatrist

Licensed Advanced Nurse Practitioner

Telephone Contact:

who is certified to provide psychiatric

or mental health services

SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of

this

day

, in the year of

Notary Seal

Notary Public

Please return completed form to:

My Commission Expires:

State of Alaska

Department of Community and

Economic Development

Division of Occupational Licensing

Board of Professional Counselors

P.O. Box 110806

Juneau, Alaska 99811-0806

08-4403c (Rev. 11/99)

Post Doctoral/master Experience Verification Form - Alaska Department Of Community And Economic Development Page 2

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