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NORTH CAROLINA PSYCHOLOGY BOARD

895 State Farm Road, Suite 101

License Applied For On Basis of:

Boone, NC 28607

[ ] ASPPB CPQ holder

(828) 262-2258

[ ] National Register of Health Services Providers

in Psychology Registrant

[ ] ABPP Diplomate

Application for Licensure Fee: $100.00

APPLICATION FOR LICENSURE

Based on Mobility Credential

Read the enclosed Information/Instructions carefully.

Type or legibly print except for signature.

To make application, a completed, signed, notarized Application Fo r Licensure Ba sed on M obility Credential, Supervision Contract

Form, and the Application Fee must be received in the Board office. Persons qualified by education to practice p sychology in N orth

Carolina must make application with 30 days of offering to practice or undertaking the practice of psychology in North Carolina. Persons

who fail to do so may not subsequently practice or offer to practice psychology without first becoming licensed. A current application form

must be completed. No application material may be faxed to the Board. Call the B oard office if you have a ny questions. Fa ilure to

com plete the process by established deadlines and in the required format will cause a delay in application review and may affect your

privilege to practice psychology. All fees are non-refundable.

01.

Legal Name

First

Middle

Last

Jr., II, etc.

02.

Home M ailing Address

County

Telephone (

)

03.

Business N ame and Ma iling Address

County

Telephone (

)

04.

Preferred Ma iling Address

Home

Business

Social Security N o.

05.

E-mail Ad dress

Daytime Fax (

)

06.

Date of Birth

Place of Birth (City/Town and State)

07.

Have you been licensed or certified by a psychology regulatory board , or made application to such a board, in another jurisdiction?

Yes

No If yes, indicate the jurisdiction, date of licensure (or status of application), expiration date, and license number.

If yes, whether an applicant or a licensee, have verification sent; see Item #1(c)(1) on Instruction sheet.

Jurisdiction

Date of Licensure

Exp iration D ate

License Number

08.

Have you previously applied for a license to practice psychology in North Carolina?

Yes

09.

Have you ever been denied a professional license or permit, or privilege of taking an examination, or had a professional license or

perm it ever disciplined in any way (e.g., denied, suspended, reprimanded, censured, restricted, limited, placed on probation, revoked,

etc) by any licensing authority in North Carolina or elsewhere, or are you aware o f any pending ch arges against a pro fessional license

or permit which you hold?

Yes

If yes, provide details on an attached sheet.

Page 1 of 3

03/08

Application For Licensure Based On Mobility Credential - North Carolina Psychology Board

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