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10.

Have you ever withd rawn a n app lication fo r licensure, or an app lication to take a p rofessio nal licensing exa mination, in North

Carolina or elsewhere?

Yes

If yes, provide details on an attached sheet.

11.

Have you ever been convicted of, or entered a plea of guilty or nolo contendere to any felony or misdemeanor other than a minor

traffic violation?

Yes

No If yes, provide details on an attached sheet and include a copy of any final judgment/order.

12.

List other fields of work for which you are, or have been, licensed or certified; or made application for licensure or

certificatio n; giving d ates and sou rces of such (e.g., boa rd, asso ciation, agenc y). Have verification sent; see Item #1(c)(6) on

instruction sheet.

Field

Source

Issue Date

Exp iration D ate

Lic/Cert #

13.

Do you hold a CPQ issued by the Association of State and Provincial Psychology Boards (ASPPB)?

Yes

If yes, have ASPPB send written verification of your CPQ status directly to the Board and give the following information:

Date CPQ issued

14.

Are you a registrant in the National Register of Health Service Providers in Psychology (NRHSPP)?

Yes

If yes, have NRHSPP send written verification of your registration directly to the Board and give the following information:

Date listed in the National Register

15.

Do you hold a diploma from the American Board of Professional Psychology (ABPP)?

Yes

If yes, have ABPP send written verification of your ABPP status directly to the Board and give the following information:

Date diplomate status awarded

Specialty

16.

Education. List full name of institution and location, beginning w ith most recent. Arran ge to have transcripts sent directly to

the Board from any institution of higher education from which you received a graduate degree or otherwise completed

gradua te course work in psychology; or if applicable, from ASPPB, NRHSPP, or ABPP. No tify the Bo ard in w riting if

transcripts will be received in a last name other than that provided under Item 01. on this application form.

College or University and

Enrollment

Date of

Degree

Major area of specialization

Location (city & state)

Date

Graduation

Awarded

(e.g., clinica l, counseling, etc.)

17.

References. Give the names and complete mailing addresses of three professional references, who are most familiar with your

current work (i.e, will have knowledge of you professionally within the last year). At least one reference must be from

a doctoral level psychologist; two references may be from other professionals. Send a copy of the REFERENCE FORM to each

reference (see instructions for further information).

Name

Mailing Address

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Application For Licensure Based On Mobility Credential - North Carolina Psychology Board Page 2

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