Fillable Verification of Licensure, Certification or Registration in (Louisiana State Board of Social Work Examiners)

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Verification of Licensure, Certification or Registration in (Louisiana State Board of Social Work Examiners)

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Louisiana State Board of Social Work Examiners

BROWSE LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS FORMS

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Louisiana State Board of Social Work
Examiners
18550 Highland Road, Suite B
Baton Rouge, LA 70809
Phone: 225-756-3470 or 1-800-521-1941 (in LA)
Fax: 225-756-3472
Website: www.labswe.org
Email: socialwork@labswe.org
Verification of Licensure, Certification or Registration in
Other State/Province
Directions for Applicant:
Complete front portion of form and forward one to each
state/province where you hold or have held a license, certification or
registration to practice social work. You are responsible for all fees relative
to verifying your credential and verifying the requirements you completed
to obtain that credential. Also, submit a copy of the state licensing law to
the Louisiana State Board of Social Work Examiners from each
state/province where license, certification or registration was held.
__________________________________
State Board/Province
I am applying for a license, certification or registration to practice social work in
Louisiana based on endorsement. I was granted license, certification or registration #
________ on _____________ by the State/Province of ________________.
The Louisiana State Board of Social Work Examiners requires official verification
directly from the credentialing body that my license, certification or registration in the
State/Province of ___________________ is in good standing.
You are hereby authorized to release any information in your files, favorable or
otherwise, directly to the Louisiana State Board of Social Work Examiners. Your prompt
attention will be appreciated.
Signature:____________________________
Print Name:___________________________
Date:______________________
Directions for State Board:
Please complete and return the original form to the Louisiana State Board of Social Work
Examiners, 18550 Highland Road, Suite B, Baton Rouge, LA 70809.
Name:___________________________________________________________
Title Granted:_____________________________________________________
License #:______________________ Date Issued:_______________________
Please verify the requirements met:
______ Bachelor’s Degree from an accredited school of social work.
______ Master’s Degree from an accredited school of social work.
______ 5,760 hours of post master’s social work experience of which 3,840
hours was under supervision, and at least 96 hours of face-to-face supervision
was provided. If not, describe the supervision received:
_____________________________________________________
Description of the supervisor’s credentials:
_____________________________________________________
Exam: ______ State Constructed Exam
*Attach copy
of score report. ______ PES (Certified Social Work Exam)
______ ASWB ______ Level
______ Endorsement-State/Province ______
______ Grandfather
License Current: ______ Yes ______ No Expiration Date:____________
Critical Information: ______ Yes ______ No
Current or Past Disciplinary Action: ______ Yes*Attach copy of report ______ No
Remarks:___________________________________________________________
___________________________________________________________
State Board/Province Signature________________________________
Seal
Print Name_______________________________
Title___________________Date______________
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Verification of Licensure, Certification or Registration in (Louisiana State Board of Social Work Examiners)

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Completed 21 July 2020

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