Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 8
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18PROFESSIONAL FITNESS:
The following questions must be answered. “Yes” answers may not automatically result in license denial.
YES
NO
1.
Have you ever been disciplined by any state board for any violations of
the Professional Counselor Practice Act or unethical conduct?
2.
Have you had a professional license denied, revoked, suspended, or otherwise restricted,
conditioned, or limited or have you surrendered a professional license, been fined, placed on
probation, reprimanded, disciplined, or entered into a settlement with a licensing authority in
connection with a professional license you have held in any jurisdiction including Alaska and
including that of any military authorities or is any such action pending?
3.
Have your ever had any malpractice settlements or judgements paid on your
behalf? (AS 08.29.400)
4.
Have you been convicted of a crime or are you currently charged with committing a crime?
For purposes of this question, “crime” includes a misdemeanor, felony, or a military offense,
including a conviction involving driving under the influence (DUI) or driving while intoxicated (DWI),
driving without a license, reckless driving, or driving with a suspended or revoked license.
“Convicted” includes having been found guilty by verdict of a judge or jury, having entered a
plea of guilty, nolo contendre or no contest, or having been given probation, a suspended
imposition of sentence, or a fine.
5.
Are you now, or within the past five years been convicted of driving under the
influence of alcohol, drugs, or chemical substance?
6.
Are you now, or within the past five years been addicted to or excessively used
or misused alcohol, narcotics, barbiturates, or habit-forming drugs?
7.
Are you now, or within the past five years have you been hospitalized for emotional or mental
illness, or have you been treated for or hospitalized for drug addiction or alcoholism?
If you answered “Yes” to any of the above questions, please explain dates and circumstances on a separate
piece of paper, and send any supporting documents that are applicable (court records, etc.).
Please be advised that all information provided with this application will be available to the public unless required to be
kept confidential by state or federal law.
I hereby certify that the information in this application is true and correct to the best of my knowledge. I understand that
any false information may result in failure to obtain licensure as a professional counselor in Alaska, or subsequent
revocation of my license.
Signature of Applicant
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:
The Board of Professional Counselors may deny, suspend, or revoke the license of a person who has
WARNING:
obtained or attempted to obtain a license to practice professional counseling by fraud or deceit. The person may also be
subject to criminal charges for perjury. (AS 11.56.200)
(Rev. 03/04/13)
08-4403
Page 8
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