Application for Licensure - Personal Information

Application Type

Please select the application type

Music Therapist

Acupuncturist

Behavior Analyst

Applicant Information

Please provide the information below.


First Name	Middle Name	Last Name	Suffix
Social Security Number	Date of Birth	Place of Birth (Include City State Country)	Gender


Have you ever been known under any other name(s)?	Yes	No
List name(s)
Will documents be received in another name?	Yes	No
List name(s)

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