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Form 08-4252 - Application To Become An Approved Marital And Family Therapy Supervisor Page 2

MFT

State of Alaska

For Division Use Only

Department of Commerce, Community and Economic Development

Division of Corporations, Business and Professional Licensing

BOARD OF MARITAL AND FAMILY THERAPY

State Office Building, 333 Willoughby Avenue, 9

Floor

PO Box 110806, Juneau, AK 99811-0806

Phone: (907) 465-5470  Fax: (907) 465-2974

E-mail: license@alaska.gov

Website:

APPLICATION TO BECOME AN APPROVED

MARITAL AND FAMILY THERAPY SUPERVISOR

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

Date of Birth:

Sex:

2. Mailing Address:

Street or P.O. Box

City

State

Zip Code

Business Telephone:

Home Telephone:

Email Address (optional):

Please send correspondence via:

US Mail

, am attesting that I have:

3. An Alaska Marital and Family Therapy License No.:

Date Issued:

4. Practiced marital and family therapy for at least five continuous years for the period from

(in accordance with AS 08.63.900(5)(A) and (B)).

Please give a brief description of your practice (in accordance with AS 08.63.900(5)(A) and (B). If more

space is needed, please attach a separate page.

OVER

08-4252 (Rev. 04/10/13)

Form 08-4252 - Application To Become An Approved Marital And Family Therapy Supervisor Page 2