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Affidavit and Release of Information (Professional Counselors)

Form Details

Owner: State, Professional Regulations - Board of Professional Counselors of Mental Health


Referring Page - Forms

Description: The undersigned applicant for Professional Counselor of Mental Health licensure, being sworn, deposes and affirms that the following is a complete list of any and all licensing jurisdictions in which s/he has formerly and currently practiced as a licensed mental-health professional. The applicant hereby authorizes all such jurisdictions to release any and all information regarding his/her disciplinary history and current status to the Delaware Board of Mental Health and Chemical Dependency Professionals.

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Enabled PDF - This type of document can be Viewed, Filled-in, Printed, and Saved to your computer for future reference. Other option may also be enabled depending on the document purpose. To open this type of document you will need to have an application installed on your computer that can read portable document files (PDF). Adobe Acrobat Reader 6.01 or higher is required to take advantage of the additional options. Get Adobe Acrobat Reader Get Adobe Acrobat

Last Updated: Thursday, 28-Feb-2013
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