Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 10
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18Has the applicant’s license been lapsed or expired?
Yes
No
If “Yes”, explain why (e.g., failure to pay
licensing renewal fees, etc.):
Has the applicant’s license ever been suspended or revoked?
Yes
No If “yes”, for what reasons?
Has the applicant been subject to any other disciplinary action(s) (e.g., letter of warning, stipulation)?
Yes
No
Please describe.
Please provide any derogatory information you believe relevant to the applicant’s qualifications to practice professional
counseling.
General Comments:
Please submit documentation of current licensure requirements.
Signature:
(Board Seal)
Printed Name:
Title:
State Board:
Date:
Address:
Please return completed form to:
Department of Commerce, Community, and
Economic Development
Phone Number:
Division of Corporation, Business and
Professional Licensing
E-mail:
Board of Professional Counselors
P.O. Box 110806
Date:
Juneau, AK 99811-0806
08-4403a
Page 10
(Rev. 03/04/13)
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