Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 6
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18PCO
State of Alaska
FOR DEPARTMENT USE
ONLY
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
Board of Professional Counselors
P.O. Box 110806, Juneau, Alaska 99811-0806
Telephone: (907) 465-2551
E-mail: license@alaska.gov
Website:
PROFESSIONAL COUNSELOR LICENSURE
APPLICATION
I HEREBY APPLY for licensure as a professional counselor by:
Examination
Credentials
This application must be completed in full. If a section does not apply, write N/A in the space provided. Please print or
type.
1. Name:
Last
First
M.I.
Maiden
Social Security Number:
Date of Birth:
Sex:
(Required by AS 08.01.060)
2. Mailing Address:
Street or Box
City
State
Zip Code
Business Telephone No.:
Home Telephone No.:
Email Address:
EDUCATION: List name and mailing address of master’s and doctorate programs attended. Give dates of attendance
and graduation.
3. College (Master):
Date Degree Awarded:
Type of Degree:
60 Masters Level Credits
4. College (Doctorate):
Date Degree Awarded:
Type of Degree:
PROFESSIONAL DATA
5. List state(s) where you currently hold or have held a license or are certified to practice professional counseling,
psychology, marital and family therapy, or social work. Please indicate whether certified or licensed.
State
Date Issued
Expiration Date
License Type
a.
b.
6. List any state(s) in which you passed/failed a professional counseling examination.
a.
State:
Exam Date:
Pass
Fail
Exam Administered by:
b..
State:
Exam Date:
Pass
Fail
Exam Administered by:
(Rev. 03/04/13)
08-4403
Page 6
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