Get Us For Board Use Only: Date: Fee: Deposit: $25

Filling out the Us FOR BOARD USE ONLY form is an important step in requesting a replacement license certificate from the Minnesota Board of Psychology. This guide will walk you through the process of completing the form accurately and efficiently online.

Follow the steps to successfully complete the form.

1. Click the 'Get Form' button to obtain the form and open it in the online editor.
2. Locate the 'DATE' field at the top of the form and enter the current date in a month/day/year format.
3. In the 'FEE' section, write the fee amount, which is $25. This amount is required to process your request.
4. In the 'DEPOSIT' field, indicate the payment method you will be using — either a check or money order made payable to the MN Board of Psychology, and note that cash will not be accepted.
5. Fill in your name as it currently appears on your license certificate by completing the 'Your name' section, providing your first, middle, and last names.
6. Select the degree on which your licensure is currently based by marking the appropriate checkbox. Options include Ph.D., Psy.D., Ed.D., or other, where you can specify.
7. Indicate your level of licensure by selecting LP or LPP.
8. Provide your mailing address for the certificate, including the street address, city, state, and zip code.
9. Enter your license number in the designated field.
10. In the 'Reason for Request' section, specify your reason, whether it's a name change or other reason. If it's a name change, you must attach a copy of the legal document that changed your name.
11. Complete the 'Name to be used on certificate' section by printing your name exactly as you want it to appear.
12. Sign the form in the designated area to authenticate your request.
13. Once you have completed all fields, review the information for accuracy. Save your changes, then download, print, or share the form as needed.

Complete your documents online to ensure a smooth application process.