Application for Licensure
Licensed Professional Counselor (advancing from LAPC)

(Please Print)

INSTRUCTIONS

1. Please provide the information requested (see additional information enclosed) .
2. Make sure that your counseling supervisor has mailed the forms that document your hours of supervision to the Board.
3. Summarize the supervision received and assess the development of your counseling (page 2).
4. Complete Statement of Intent (page 3).
5. Sign Affidavit (page 4) .
6. Mail completed application to the following address:
North Dakota Board of Counselor Examiners
2112 10th Ave. SE
Mandan, ND 58554

FEES: Attach license fee of $100.00

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

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

YESNO

1. Have you been convicted of a felony since receiving your associate license? . . .

____
2. Have you become dependent upon, evaluated for, and/or received treatment for drug or alocohol abuse since receiving your associate license? . . .____

3. Have you had a malpractice judgment issued against you since receiving your associate license? . . .

____
4. Have you become impaired from effectively providing counseling services since receiving your associated license? . . .____

Page 1 - After printing this out, click here to go to the next page.