Name of Applicant: (Required)
APPLICATION VALIDATON - To be completed by all applicants.
North Carolina Board of Licensed Clinical Mental Health Counselors
Licensure Application Affidavit
This form must be signed and dated in the presence of a Notary Public.
To be completed by applicant:
I declare and arm all of the following:
I am the person who executed this applicaon.
The statements contained on this applicaon including accompanying documents, are true and complete in every aspect.
I have not suppressed or withheld informaon that might aect this applicaon.
I will comply with all legal and ethical standards and standards of pracce in my professional conduct, as required by the
NC Licensed Professional Counselors Act and the ACA Code of Ethics.
I have read and understand this adavit.
I understand that any false or misleading informaon in, or in connecon with, my applicaon may be cause for denial of licensure,
disciplinary acon against a license, or revocaon of a license. I also understand that the Board has the authority to conduct a full
criminal record search, including state and naonal records.
Applicant’s Full Name (PRINTED): _______________________________________________________________
Applicant’s Signature: ________________________________________________ Date: ___________________
Notary Informaon:
State of __________________________________________________
City/County of __________________________________________
Sworn to (or armed) and subscribed before me, on this,
the ____________ day of ______________________ in the year __________, and proved to me on the
basis of sasfactory evidence to be the individual whose name is subscribed to this applicaon and
acknowledged to me that he/she executed the applicaon and swore that the statements made by him/her
in the applicaon and all supporng materials are true, complete, and correct.
Notary Public Signature: _______________________________________________________________
My Commission Expiries: _______________________________
Upload the completed form in the Counselor Gateway or mail to: NCBLCMHC • PO Box 77819 • Greensboro, NC 27417
Revised 2/13/2020This version supersedes all previous versions Application Affidavit
SEAL
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
