*Required

*Applicant Name

APPLICATION FOR LICENSURE

All application materials must be in the Arkansas Board of Examiners office one (1) month prior to the
registration deadline date given for the NCE or MFT examination.

Applicant must be a citizen of the United States or have a current green card issued by the U.S. Immigration
Bureau documenting legal alien work status in the U.S.

Licensed Associate Counselor (LAC)

Associate Marriage & Family Therapist (AMFT)

Licensed Professional Counselor (LPC)

Marriage & Family Therapist (MFT)
(An application fee of $200.00 must accompany the submission of this completed form.)

Date of Birth

Name(s) on transcript(s) if different from above

Birthplace

City

State

County

Other (Please explain)

United States Citizen

Yes
No - If no, attach a copy of your current green card issued by U.S. Immigration Bureau, to document and verify legal alien work status in the U.S.

*Current Residential Address

P.O. Box

*City

*State

*Zip

*Home Phone

Work Phone

Fax

*Email Address

Work Experience (cite most recent first):
Position Responsibilities Supervisor Dates

Professional Training (cite most recent first):
Dates College/University Specialization Credential/Degree

Do you intend to apply for a specialty designation?

Yes
No

If Yes, please name the specialty

Do you possess professional license(s) or certificate(s) issued by any state?

Yes
No

If answer is yes, give license or certificate number(s), title(s), and states issuing license(s) or
certificate(s)

Have you ever denied a license and/or certification?

Yes
No

If answer is yes, briefly state reasons

Have you ever had your license or certificate revoked, canceled or suspended?
Yes
No

If answer is yes, state reasons

Have you ever been convicted of a felony?
Yes
No

If answer is yes, please provide the following information

Date of conviction

Where convicted

Felony charge

Current Employment Information

Primary Employment Setting

Name of Employer

Address

Phone

Setting

Independent private practice

School

Governmental agency

Non-profit organization

(Employed) private practice

Other (Please Explain)

Secondary Employment Setting

Name of Employer

Address

Phone

Setting

Independent private practice

School

Governmental agency

Non-profit organization

(Employed) private practice

Other (Please Explain)

Name and degree of supervisor(s)

Position of supervisor(s)

Licensure status