APPLICATION FOR LICENSE PSYCHOLOGIST Please enable JavaScript in your browser to complete this form.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? YesNoIf yes, complete the following:Business Name *Business Address *City *State *Zip Code *Business Phone *Have you been license or certified by a psychology regulatory board in any jurisdictions, or made an application to such a board?YesNoIf you answered yes above, indicate the jurisdiction, date of licensure of certification, and license or certificate number. If only an applicant, indicate the jurisdiction and status of application. Have you passed the examination for professional practice in Psychology?YesNoIf so, in which state(s)? Have you ever been denied a professional license or certificate, or 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?YesNoIf yes to any, provide details on an attached sheet. Click or drag files to this area to upload. You can upload up to 5 files. 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?YesNoIf yes to any, provide details on an attached sheet. Click or drag files to this area to upload. You can upload up to 5 files. What do you consider your primary area of specialty in psychology? (check one) Clinical Counseling School Other (specify)..What do you consider your primary area of specialty in psychology?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? YesNoIf yes, give the date of full APA approval.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, #HoursProfessional 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. Click or drag a file to this area to upload. Upload Affidavit, Verification of Licensure and Authorization for Release of Information Click or drag files to this area to upload. You can upload up to 4 files. Single Item *Price: $ 175.00Submit
