Certification Of Clinical Practice Form Page 2
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2Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
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Parent category: Business