Get 670105 Fillable Form

Completing the 670105 Fillable Form online is a straightforward process that allows you to efficiently apply for the Social Worker Associate Independent Clinical License. This guide will walk you through each section of the form, ensuring you understand the requirements and how to provide the necessary information.

Follow the steps to complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin with the Demographic Information section. Enter your social security number, legal name, national provider identifier number, birth date, and place of birth accurately. Ensure all names match your official documentation.
3. Fill in your contact information, including your address, phone numbers, and email. If your mailing address differs, provide that information as well.
4. Answer the personal data questions thoughtfully. If you respond 'yes' to any question, provide a detailed explanation as required.
5. List your educational history in the Education section, including the institutions you attended, the degree received, and request the official transcripts to be sent directly to the Department of Health.
6. Complete the section on Other Licenses, Certifications, or Registrations by listing any credentials held in Washington and other states. Remember to provide the Out-of-State Credential Verification Form to the respective states.
7. Declare that you are working toward licensure as a social worker by initials and date in the Declaration Working Toward Licensure section.
8. Complete the AIDS Education and Training Attestation to confirm you have met the training requirements.
9. Sign and date the Applicant’s Attestation section. Ensure the information provided is accurate and complete.
10. Review the completed form for accuracy. Save your changes, and you have the options to download, print, or share the form as needed.

Start completing your documents online today!