Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 9
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18STATE OF ALASKA
BOARD OF PROFESSIONAL COUNSELORS
VERIFICATION OF LICENSURE
Applicant:
Some states require a fee for completion of a license verification; you may wish to check with the state board prior to
submitting this form for completion.
State Board:
I am applying for a license to practice professional counseling in the State of Alaska. The Alaska Board of Professional
Counselors requires that this form be completed by each jurisdiction in which I hold or have held a license. Please
complete the form and return it to:
State of Alaska
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
Signature:
Printed Name:
Name at Time License Issued:
License Number:
Address:
PLEASE DO NOT DETACH
The information below must be completed by the State Licensing Board; it may not be completed by the
applicant.
State of
Board of
Name of Licensee
Graduate of
Type of License Held
License No.
Issued Effective
License is Current
Lapsed
Expiration Date
By Reciprocity/Endorsement
By Examination
Date of Exam
Percent Score
Raw Score
Examination administered by
Licensee received at least
year(s) of supervised experience during the period from
to
08-4403a
Page 9
(Rev. 03/04/13)
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