Professional Licensure/Certification

1. First name*

2. Last name*

3. Type of professional license:*

If other:

4. Professional license renewal date:

5. State where you have your professional license:

6. What is the relevant credential in which you can provide professional supervision to count towards licensure/certification for a supervisee (i.e.; LCPC Board Approved Supervisor) or N/A?

7. What Board or Professional Entity issues your professional license?

8. What is the fee to renew your professional license?

9. Will you have what you need (training, funding, etc.) to renew your professional license in time?

10. Are you currently pursuing a professional license that you do not already have?

11. If so, what type of professional license are you pursuing?

12. What is the expected date of attainment of the above professional license you are pursuing?

13. Is the professional license required for your position with VOAC?