Get Attachment A

Filling out the ATTACHMENT A form for the psychology license application is an essential step in your journey to becoming a licensed psychologist in Nebraska. This guide provides detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the ATTACHMENT A form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, provide your personal information. Fill in your legal name, including your first name, middle initial, and last name. Indicate your maiden name and any other names you may be known by. Additionally, complete your mailing address, place of birth, date of birth, and select the appropriate box for your identification number, whether it is a Social Security Number, Alien Registration Number, or Form I-94.
3. In Section B, select the appropriate category for your licensure application. This includes options such as initial licensure in Nebraska, reciprocity, or temporary licenses. Review the fee chart and indicate the applicable fee amount based on the month of submission.
4. Complete Section C if you have taken the Examination for Professional Practice of Psychology (EPPP) in a state other than Nebraska. Provide the date of the examination and the city and state where it was administered.
5. In Section D, disclose any conviction and licensure information. You must answer whether you have ever been convicted of a misdemeanor or felony, and provide detailed explanations as necessary.
6. In Section E, list your internship experience. Include the name of the facility, address, dates of the internship, supervisor's name, and credentials of the supervisor. Indicate whether the internship was APA-approved.
7. Continue to Section F to report on your postdoctoral supervised experience. Answer questions about completion, provide information about your facility, dates of experience, and supervisor.
8. Filling Section G is necessary for education. Enter details about your doctoral degree, include the last name on the transcript, institution name, and graduation information.
9. If applicable, complete Section H for reciprocity. Indicate if you have practiced psychology actively and continuously under license in another jurisdiction.
10. In the final sections, answer questions related to practice prior to credentialing, attestations, and compile any required supporting documents as specified in the guidance.
11. Once all sections are completed, save changes, download, print, or share the form as needed.

Start filling out the ATTACHMENT A form online today to advance your psychology licensing process.