Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 14
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18For the Board of Professional Counselors to have sufficient information to assess the applicant’s qualifications, please
answer the following questions:
To your knowledge:
YES
NO
1.
Is the applicant of good moral character? ...............................................................................................
7.
Is the applicant currently or been within the past five years addicted to or excessively
used alcohol, narcotics, barbiturates, or habit-forming drugs? ...............................................................
8.
Has the applicant ever been disciplined or sanctioned by another state or jurisdiction? .......................
9.
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? .........................................................................................................................................
10. Has the applicant misrepresented his or her qualifications to the board in any way? ............................
11. Has the applicant been sanctioned for practicing professional counseling, psychology,
marital and family therapy, or social services without a license? .............................................................
7.
Would you evaluate the applicant’s technical knowledge and practical experience to be
Excellent
Very Good
Fair
Needs Improvement
8.
Would you recommend this person for licensure as a professional counselor? ......................................
9.
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.
Name (Print or Type):
Signature:
Do you hold a Professional License?
Yes
No
If “yes”, list License type, number and state where held:
Type:
Number:
State:
Institution/Clinic Where Employed:
Address:
Street or PO Box
City
State
Zip
Telephone Contact:
SUBSCRIBED AND SWORN TO before me, a Notary Public, in and for the State of
this
day
of
, in the year of
.
Notary Seal
Notary Public
My Commission Expires:
08-4403b
Page 14
(Rev. 03/04/13)
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