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Get CA BBS 37M-469 2011

Suite S200 Sacramento CA 95834 Telephone 916 574-7830 TTY 800 326-2297 www. bbs. ca.gov REQUEST FOR ADDRESS CHANGE REQUEST FOR REPLACEMENT LICENSE OR REGISTRATION Check all licenses or registrations applicable to this CHANGE OF ADDRESS Request. STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY Governor Edmund G* Brown Jr. Board of Behavioral Sciences 1625 North Market Blvd. Enter license or registration number and expiration date. Associate Clinical Social Worker Marriage and Family Therapist Intern Professional Clinical Counselor Intern Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Educational Psychologist Licensed Professional Clinical Counselor Continuing Education Provider Please type or print legibly in ink. Legal Name as it appears on your license or registration NEW Address of Record ASW IMF PCI LCS MFC LEP LPC PCE Last City Yes Middle State Residence or Business Phone Number Are you currently in the examination process Expiration Date First Number and Street Social Security Number Not required for CE Providers Zip Code Email Address No Request for Replacement License/Registration You may request a replacement license/registration which will reflect your new address by completing the section below and returning it with the required document and fee. For Office Use Only Check type of document being requested Cashiering No* Engraved license certificate 8 x 11 Date ordered by Original or renewal license/registration 8 x 3 5/8 Submit a 20 fee for each replacement document requested Document to be replaced must be returned with this application or you must state the circumstances regarding the loss of the document here please print clearly I hereby certify under penalty of perjury under the laws of the State of California that the foregoing are true and correct. Signature of Licensee/Registrant Date Business and Professions Code Sections 4982 b 4992. 3 b 4989. 54 b and 4999. 90 b give the Board the right to refuse to issue any registration or license or may suspend or revoke the license or registration of any registrant or licensee if the applicant secures the license or registration by fraud deceit or misrepresentation on any application for licensure or registration submitted to the Board. The address you enter on this application is public information and will be placed on the Internet pursuant to Business and Professions Code Section 27. If you do not want your home or work address available to the public please provide an alternate mailing address. Enter license or registration number and expiration date. Associate Clinical Social Worker Marriage and Family Therapist Intern Professional Clinical Counselor Intern Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Educational Psychologist Licensed Professional Clinical Counselor Continuing Education Provider Please type or print legibly in ink. Legal Name as it appears on your license or registration NEW Address of Record ASW IMF PCI LCS MFC LEP LPC PCE Last City Yes Middle State Residence or Business Phone Number Are you currently in the examination process Expiration Date First Number and Street Social Security Number Not required for CE Providers Zip Code Email Address No Request for Replacement License/Registration You may request a replacement license/registration which will reflect your new address by completing the section below and returning it with the required document and fee. .

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