APPLICATION FOR LICENSE PSYCHOLOGIST - USVI Board of Psychology Examiners

APPLICATION FOR LICENSED PSYCHOLOGIST

Name *

Email *

Social Security Number *

Date of Birth *

Place of Birth *

Residential Address *

City *

State *

Zip Code *

Mailing Address *

City *

State *

Zip Code *

Residential Phone *

Are you currently involved in the practice of psychology?

Yes
No

Zip Code *

Business Phone *

Have you been licensed or certified by a psychology regulatory board in any jurisdictions, or made an application to such a board?

Yes
No

Have you passed the examination for Professional Practice in Psychology?

Yes
No

Have you ever been licensed?

Yes
No

Have you ever been denied a professional license or certificate, or the privilege of taking an examination, or had a professional license or certificate ever disciplined in any way (eg. denied, suspended, reprimanded, censured, restricted, limited, placed on probation, revoked, etc.) by any licensing authority?

Yes
No

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

Yes
No

What do you consider your primary area of specialty in psychology? (check one)

Clinical
Counseling
School
Other (specify)..

List the full name of all psychological organizations of which you are a member.

If applying on the basis of a doctoral degree, was your doctoral program APA accredited through the duration of your enrollment in the program?

Yes
No

Education: List the full name of the Institution, Department, City, State, Date Enrolled, Date Graduated, Awarded, and Major beginning with the most recent.

Specialty Training/Continuing Education: (Note all significant training.)

Please Include Course Sponsor, Course Name, Course Location, #Days, #Hours

Professional Experience and Employment: List all professional experience in chronological account order, beginning with the present position, to cover the complete time from, and including any graduate practicum, internships, etc.

Also include any periods of unemployment, employment in fields other than psychology, etc. (i.e., do not leave any gaps in time).

Education: List the full name of the Institution, Department, City, State, Date Enrolled, Date Graduated, Awarded, and Major beginning with the most recent.