Application For Psychology License Form - Bureau Of Occupational Licenses, State Of Idaho Page 2
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4APPLICATION FOR PSYCHOLOGY LICENSE
(continued)
15. Have you ever taken the National Examination for the Professional Practice of Psychology (EPPP)?
[ ]Yes
[ ]No
(If Yes, we must receive official certification from the interstate reporting service before your application will be processed.)
16. Are you currently or have you ever been licensed in another state?
[ ]Yes
[ ]No
(If Yes, we must receive certification of licensure directly from the issuing authority before your application will be processed. If your
license is current, you must attach a complete copy of the applicable state's licensure requirements and complete Addendum 2.)
17. Have you ever had a license, certification, or registration revoked, suspended or otherwise sanctioned? [ ]Yes
[ ]No
(If yes, a copy of the charges and the final order must be received before your application will be processed.)
18. Have you ever been convicted of any State or Federal felony?
[ ]Yes
[ ]No
(If yes, a detailed statement, a summary of the charges, the final order, any probation or parole documentation, and any other
relevant information must be received before your application will be processed.)
19. Please attach the names and current addresses of three (3) persons willing to provide reference regarding your character,
training, and experience. (This office will send the required forms to the persons you list. We must receive a letter of reference
from each person listed before your application will be processed.)
_________________________ _________________________ _________________________
name
name
name
_________________________ _________________________ _________________________
position & license number
position & license number
position & license number
_________________________ _________________________ _________________________
current address
current address
current address
_________________________ _________________________ _________________________
city, state, zip
city, state, zip
city, state, zip
AFFIDAVIT
I hereby certify that the responses provided above and those attached to this application are true and accurate to the best of my
knowledge and belief. I further certify that I have received and will comply with the Idaho Laws and Rules governing the practice of
Psychology and the Ethical Principles of Psychologists of the American Psychological Association.
I hereby authorize and direct any person, agency, firm, or other entity to release, upon the request of the Bureau of Occupational
Licenses or it’s authorized representative, any information, communication, report, record, statement, recommendation, or disclosure
that may have bearing on my eligibility for or maintenance of the license for which I am applying.
I understand that by signing this form I am authorizing the release of information about me that may otherwise be protected or
confidential.
_____________________________________________________
Signature of applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 19 _____.
______________________________________________________
(seal)
Notary Public official signature
residing at_____________________________________________
my commission expires___________________________________
(continued)
BOL – PSY-1 - revised 05/24/99
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