(please print or type)

NAME _________________________________________________ LPC Lic. # ________________

MAILING ADDRESS _____________________________________________________

SS# _____________________ PHONE _______________________________________

Please indicate below how you meet the requirements for the privilege to utilize formal appraisal instruments in the appraisal of individuals.

STATISTICS

Course: _________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: _____________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

SAMPLING THEORY

Course: _________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: _____________________________________________________________

_______________________________________________________________________

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TEST CONSTRUCTION

Course: ________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: ______________________________________________________________

_______________________________________________________________________

________________________________________________________________________

TEST AND MEASUREMENTS

Course: _________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: ______________________________________________________________

________________________________________________________________________

________________________________________________________________________

INDIVIDUAL DIFFERENCES

Course:_________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: ______________________________________________________________

________________________________________________________________________

________________________________________________________________________

PRACTICUM

Course: _________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: ______________________________________________________________

________________________________________________________________________

________________________________________________________________________

SUPERVISED PRACTICE

Course:_________________________________________________________________

In support: Transcript only ___ Catalogue ___ Letter ___ Other ___

Comments: ______________________________________________________________

________________________________________________________________________

________________________________________________________________________

I hereby affirm that I am the person referred to in this application for the privilege to utilize formal appraisal instruments in the appraisal of individuals. All of the foregoing statements and enclosures are true in every respect. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for denial, suspension, or revocation of such privilege and/or of the license to practice mental health counseling in the State of Louisiana.

The Board of Examiners reserves the right to secure further evidence that it deems reasonable and proper from the sources above.

Signature of Applicant _______________________________ Date ______________

APPLICATION CHECKLIST

___ Licensed professional counselor

___ Transcript on file with the Board

___ Other supporting evidence on file with the Board or included with application.

of Examiners included with application. Personal checks are not accepted.

___ Signature on application