Fillable Verification of Experience (Utah DRE)

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Verification of Experience (Utah DRE)

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The Verification of Experience (Utah DRE) form is 1 page long and contains:

  • 1 signature
  • 8 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
Verification of Experience
Each supervisor must complete a separate form. The hours of all forms must total 1,500 for a Behavior Analyst
or 1,000 for an Assistant Behavior Analyst.
APPLICANT INFORMATION
To be completed by the applicant.
Full Legal Name:
First
Middle
Last
Mailing Address:
Street/PO Box
City
State Zip
EMPLOYMENT INFORMATION
To be completed by the Supervisor.
Name of Establishment:
Name of Supervisor:
License Number:
Establishment Address:
City
State Zip
Telephone Number:
Email:
Dates of Employment/Supervision:
to
MM/DD/YYYY
MM/DD/YYYY
How many hours per week did the applicant work?
Part time Full Time
Total Hours Supervised Practice:
Describe the applicant’s duties:
Is the applicant currently employed with the facility? Yes No
If no, is the applicant re-hirable? Yes No, Please
explain:
I
do hereby certify that the applicant for licensure as
(select one):
Behavior Analyst
Assistant Behavior Analyst
has successfully completed the above hours of supervised experience. I certify that the experience supervised meets
the requirements outlined UCA 58-61-705 and defined in R156-61a-702.
I
further certify that the applicant is qualified and competent to practice as a
(select one):
Behavior Analyst
Assistant Behavior Analyst
S
ignature of Supervisor: ______________________________________________ Date: _____________________
F-61BA-V
20201104
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Verification of Experience (Utah DRE)

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Completed 3 December 2020

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