Fillable CALIFORNIA PSYCHOLOGY LAW AND ETHICS EXAMINATION REQUEST FORM (California)

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CALIFORNIA PSYCHOLOGY LAW AND ETHICS EXAMINATION REQUEST FORM (California)

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www.psychology.ca.gov
P (916) 574-7720 / F (916) 574-8671
1625 N. Market Blvd. N-215, Sacramento, CA 95834
(Revised 05/21)
CALIFORNIA PSYCHOLOGY LAW AND ETHICS
EXAMINATION REQUEST FORM
GAVIN NEWSOM, GOVERNOR
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
21_098
ADMINISTRATION
To be eligible to take the California Psychology Law and Ethics Examination (CPLEE), please mail this
completed form with a check or money order payable to the Board of Psychology in the amount of $129 to:
Board of Psychology, 1625 North Market Blvd., Ste. N-215, Sacramento CA 95834. The Board is currently unable
to accept credit card payments. If you have any questions, contact the Board at (916) 574-7720, ext. 3, or by
e-mail at bopmail@dca.ca.gov.
DO NOT SUBMIT THIS FORM AND PAYMENT IF YOU HAVE NOT YET TAKEN AND PASSED
THE EXAMINATION FOR PROFESSIONAL PRACTICE OF PSYCHOLOGY (EPPP).
Please check all box(es) below that apply:
c
I have recently passed the EPPP and am applying to take the CPLEE.
c I have served or I am currently serving in the military.
c I am married to, or in a domestic partnership or other legal union with, an active duty member of the
Armed Forces of the United States who is assigned to a duty station in California under active duty military
orders AND I hold a current psychology license in another state, district, or territory of the United States.
c I have been licensed in another state, Canadian province, or U.S. territory for more than ve years.
c I have a Certicate of Professional Qualication (CPQ) issued by the Association of State and Provincial
Psychology Boards (ASPPB).
c I have a credential as a Health Service Provider in Psychology by the National Register of Health Service
Providers in Psychology (NRHSPP).
c I am certied by the American Board of Professional Psychology (ABPP).
c I’m requesting to take the CPLEE based on probationer status.
Have you previously taken the CPLEE? c Yes (Last date taken: _______________) c No
Do you require reasonable accommodations? c Yes c No
Name (please print): ____________________________________________________________________________
File ID #: _________________________________ E-mail Address: _______________________________________
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CALIFORNIA PSYCHOLOGY LAW AND ETHICS EXAMINATION REQUEST FORM (California)

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Completed 19 August 2021

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