The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
Licensed Clinical Social Worker Form 4
Applicant Experience Record
Applicant Instructions
1. Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to
sign and date item 10.
2. For your experience to be considered, you must also complete Section I of Form 4B and forward the entire form and a copy of
Appendix A to each supervisor you list in item 9 on this form.
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date
Month Day Year
3. Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)
4. Mailing Address (You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
State ZIP Code
5. Telephone/Email Address
Daytime Phone
Area Code Phone
Email Address (please print clearly)
6. New York State Licensed Master Social Worker License Number
7. Date of award of Graduate Social Work Degree
mo. day yr.
8. Give any other names by which you have been known
Licensed Clinical Social Worker Form 4, Page 1 of 2, Revised 8/17
9. List supervisor(s) who will verify your experience for licensure as an LCSW. The supervisor(s) must be an LCSW, licensed psychologist or
psychiatrist for experience in New York State. Attach additional sheets if necessary.
The supervisor(s) listed must have supervised your post-M.S.W. experience in diagnosis, psychotherapy and assessment-based
treatment plans.
If a supervisor is deceased, you should list a licensed colleague who will attest to your supervised experience and to the qualifications of
the deceased supervisor.
Name of Supervisor and Address of Experience Setting
Dates of Experience
From To
10. Attestation
I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and
correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of
qualification and may lead to a filing of charges of professional misconduct.
Applicant's Signature Date
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Social Work
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Licensed Clinical Social Worker Form 4, Page 2 of 2, Revised 8/17
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