Application for Licensure
LAPC or LPC

(Please Print)

INSTRUCTIONS

1. Please provide the information requested (see additional information enclosed) .
2. If additional space is needed, please attach a separate sheet.
3. Completed applications should be mailed to the following central address:
North Dakota Board of Counselor Examiners
2112 10th Ave. SE
Mandan, ND 58554

FEES: Attach application fee of $150.00 ($50.00 of which is non-refundable).
* This application will be valid for one year from submission date. If licensure process is not completed, $100 will be automatically refunded. Applicant may reapply.

A. GENERAL INFORMATION

SOCIAL SECURITY NUMBER COUNSELOR LICENSE NUMBER
NAME (Last, First, Middle Initial) TELEPHONE NUMBER
Home:
Work:
MAILING ADDRESS (Street and/or PO Box No., City, State, Zip)


E-MAIL ADDRESS

LICENSE FOR WHICH YOU ARE APPLYING (Check one)

____ LICENSED ASSOCIATE PROFESSIONAL COUNSELOR (LAPC)-(omit Section F)
____ LICENSED PROFESSIONAL COUNSELOR (LPC)-(omit Section D)

MAJOR AS IT APPEARS ON GRADUATE TRANSCRIPT

B. ANSWER THE FOLLOWING QUESTIONS (yes, answers must be explained in an attached statement).

YES NO

1. Has your application for license ever been refused? . . .

__ __
2. Has your license ever been revoked or have you ever been the subject of disciplinary action by any licensing agency? __ __

3. Have you ever been convicted of a felony? . . .

 __ __
4. Are you currently experiencing any incapacity that would prevent you from effectively practicing counseling? . . . __ __
5. Have you ever had a malpractice judgement issued against you?. . . __ __

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