Application for Licensure
Licensed Professional Clinical Counselor (LPCC)

(Please Print)

INSTRUCTIONS

1. Please provide the information requested (see additional information enclosed).
2. If more space is needed to provide additional information, please attach a separate sheet.
3. Mail completed application to the following address:

North Dakota Board of Counselor Examiners
 2112 10th Ave. SE
Mandan, North Dakota 58554

FEES: Attach application fee of $150.00. This application will be valid for one year from submission
date. If licensure process is not completed, 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

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? . . .____

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