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How to use or fill out California Form in State Verification

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the 'APPLICANT NAME' section, including your last, first, and middle names along with your intern number.
Fill out the 'SUPERVISOR INFORMATION' section. Include the supervisor's last name, address, license type, and license number. Specify the dates of experience being claimed.
Answer the questions regarding your experience settings by selecting 'Yes' or 'No' for each item listed under 'APPLICANT’S EMPLOYER INFORMATION'.
In the 'EXPERIENCE INFORMATION' section, indicate how many weeks of supervised experience you are claiming and log your total direct counseling hours.
Ensure all information is accurate before signing. Have your supervisor initial any changes made on the form.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (192 Votes)
2015	4.4 Satisfied (327 Votes)

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