Form 08-4252 - Application To Become An Approved Marital And Family Therapy Supervisor Page 3

5. Met the education requirements as found in AS 08.63.100(a)(3)(B).

Yes, I meet the education requirements

No, I do not meet the education requirements.

I 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 marital and family therapy approved supervisor in

Alaska, or subsequent revocation of my license.

Signature of Applicant

SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of

this ________ day of

in the year of __________.

Notary Public

My Commission Expires:

WARNING: The Board of Marital and Family Therapy may deny, suspend, or revoke the license of a person

who has obtained or attempted to obtain a license to practice marital and family therapy by fraud or deceit.

The person may also be subject to criminal charges for perjury. (AS 11.56.200)

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

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