Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 7
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18If applying for licensure by credentials, upon what state license do you base this application?
License Number:
Date of Issuance:
State:
8. Do you hold any other professional license?
Yes
No
If yes, type of license held and number______________________________________
OCCUPATIONAL DATA – In chronological order, from most recent to most remote for the last five years, list all relevant
or related professional positions held. Provide name of employer, mailing address, phone number, position held, duties
and responsibilities, and name of direct supervisor(s).
ALL APPLICANTS MUST COMPLETE THIS SECTION.
However, only those applying by examination need to complete the information regarding supervision (*).
9. Name of Employer:
Dates:
From
to
Employer full address:
Employer Telephone number:
Position held by applicant:
Duties and responsibilities:
*Name and degree of supervisor:
*Total number of supervised hours:
*Total number of direct counseling hours:
*Total number of face-to-face supervision:
Name of Employer:
Dates:
From
to
Employer full address:
Employer Telephone number:
Position held by applicant:
Duties and responsibilities:
*Name and degree of supervisor:
*Total number of supervised hours:
*Total number of direct counseling hours:
*Total number of face-to-face supervision:
Name of Employer:
Dates:
From
to
Employer full address:
Employer Telephone number:
Position held by applicant:
Duties and responsibilities:
*Name and degree of supervisor:
*Total number of supervised hours:
*Total number of direct counseling hours:
*Total number of face-to-face supervision:
(If you need additional pages, please attach.)
08-4403
(Rev. 03/04/13)
Page 7
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