STATE OF CALIFORNIA - BUSINESS, ONSUMER SERVICES AND HOUSING AGENCY
Gavin Newsom, Governor
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830
www.bbs.ca.gov
REQUEST FOR LICENSE OR REGISTRATION CERTIFICATION
For Office Use Only
REQUIRED FEE MUST ACCOMPANY THIS FORM
Make check payable to - Behavioral Sciences Fund
Cashiering No.
FEE
$25 per Certificate
1) I hereby request certification of license or registration status for the following:
Licensed Marriage and Family Therapist (LMFT)
Marriage and Family Therapist Intern (IMF)
Associate Clinical Social Worker (ASW)
Licensed Educational Psychologist (LEP)
Professional Clinical Counselor Intern (PCCI) Licensed Professional Clinical Counselor (LPCC)
Licensed Clinical Social Worker (LCSW)
A Certification of License will include current license status, any disciplinary action taken against the license, and renewal
information.
2) Number of certifications requested ($25 per certificate requested):
_______
3) Requestor Information
Please type or print clearly in ink
Name of Requester:
Requestor Mailing Address :
Number and Street City State Zip Code
Requestor Telephone: Fax Number: Email Address:
4) Certification requested for the following licensee/registrant:
Name of Licensee or Registrant:
License or Registration Number:
5) The certification will be mailed to the following location(s):
Attach additional addresses if necessary
Name:
Company Name
(if applicable)
:
Mailing Address : Number and Street City State Zip Code
Business Telephone:
Fax Number:
Email Address:
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37M-800 (Rev. 2/12)
Continued
Name:
Company Name
(if applicable)
:
Mailing Address :
Number and Street City State Zip Code
Business Telephone: Fax Number: Email Address:
This certification is provided in good faith. If the fee does not clear the financial institution, this certification is considered
invalid and the licensee will be notified immediately.
37M-800 (Rev. 2/12)
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