Transcription of APPLICATION FOR CLIINICAL PROFESSIONAL COUNSELOR …
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APPLICATION FOR CLIINICAL PROFESSIONAL COUNSELOR …
BRIAN SANDOVAL NEVADA STATE board OF EXAMINERS FOR PO Box 370130 Governor MARRIAGE & FAMILY THERAPISTS AND Las Vegas, Nevada 89137 CLINICAL PROFESSIONAL COUNSELORS Office: (702) 486-7388 Quinn Kennedy Fax (702) 486-7258 Interim Executive Director 1 Updated 7/16 APPLICATION FOR CLIINICAL PROFESSIONAL COUNSELOR LICENSURE APPLICATION Fee: $ check or money order made payable to: NV State board of Examiners MFT & CPC I. APPLICANT IDENTIFICATION INFORMATION: Internship Licensure Interim Permit 1. Last Name First Name Middle Name (Maiden) Other Names or AKA 2. Home Address City State Zip Social Security 3. Home Phone Number Cell Phone Number Email Address Date of Birth 4. Primary Employer Name of Supervisor Business Telephone/Ext. 5.
NEVADA State Board of Examiners – MFT & CPC CPC Application – Page 2 . 2 . III. EXAMINATION: ... An applicant who is currently licensed and in good standing as a clinical professional counselor in another state or jurisdiction may be eligible for licensure, …
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