Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 16

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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:

To your knowledge:

YES

Is the applicant of good moral character? ...............................................................................................

Is the applicant currently or been within the past five years addicted to or excessively used

alcohol, narcotics, barbiturates, or habit-forming drugs? ........................................................................

Has the applicant ever been disciplined or sanctioned by another state or jurisdiction? ......................

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? .........................................................................................................................................

Has the applicant misrepresented his or her qualifications to the board in any way? ............................

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