Registrant Request For Initial California Law And Ethics Examination
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2STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
Governor Edmund G. Brown Jr.
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830 TTY: (800) 326-2297 FAX: (916) 574-8626
REGISTRANT REQUEST FOR
INITIAL CALIFORNIA LAW AND ETHICS EXAMINATION
• This form will NOT be accepted unless you have already been issued a registration as an
ASW, MFT Intern, or PCC Intern (registration can be current, delinquent or cancelled).
• The California Law and Ethics Exam is different for each license type. A separate request form
and $100 fee is required for each exam.
• To confirm receipt, mail this form using a method that includes tracking. Processing times will
vary depending on application volumes.
For Office Use Only
$100 FEE MUST ACCOMPANY THIS FORM
Cashiering No
.
Make check payable to - Behavioral Sciences Fund
(Type or print clearly in ink)
1. SSN or ITIN*:
2. Registration Type:
3. Registration Number:
ASW
MFTI
PCCI
4. Exam Type:
LCSW Law and Ethics Exam
SELECT ONLY
LPCC Law and Ethics Exam
ONE
LMFT Law and Ethics Exam
5. Legal Name:
Last
First
Middle
6. Address of Record**:
Number and Street
City
State
Zip Code
7. Is this a new address?
Yes
No
If YES, we will update our records accordingly
8. Business Telephone:
9. Residence Telephone:
10. E-Mail Address (OPTIONAL):
NOTE: Knowingly providing false information or omitting pertinent information may be
grounds for denial of this application.
Signature of Applicant
Date
* You may provide either your Social Security Number, your Federal Employer Identification
Number, or Individual Taxpayer Identification Number, as applicable
37A-509 (Revised 01/2017)
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