Fillable NEVADA STATE BOARD OF PSYCHOLOGICAL EXAMINERS Application for (State of Nevada, Department of Information Technology)

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NEVADA STATE BOARD OF PSYCHOLOGICAL EXAMINERS Application for (State of Nevada, Department of Information Technology)

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v2; Revised: 4/15/2021
NEVADA STATE
BOARD OF PSYCHOLOGICAL EXAMINERS
Application for Licensure as a Psychologist
For additional information about licensure in the State of Nevada, contact the Board office at
nbop@govmail.state.nv.us, 1-775-688-1268, or https://psyexam.nv.gov/Forms/ALL/PsychologistAppInfo/
.
Type or Print Legibly in Ink
Application Date: _____________________________
1. Acknowledgement
Any omissions, false or misleading information in, or connected with, this application, its attachments or other
communications with the Board may be cause for denial or revocation of licensure.
2. Personal Data
Degree: Ph.D. _____ Psy.D. _____ Ed.D. _____
Applicant Name: _____________________________________________ _______________________
Last Maiden (if applicable)
__________________________________________ _____________________________
First Middle
Social Security #: ____ - ___ - _____ U.S. Citizen: Yes ___ No ___ Gender: ____________
Place of Birth: ___________________________________________ Date of Birth: _________________
U.S. Armed Services: Are you an active member or veteran of the U.S. Armed Forces? Yes ___ No ___
Are you the current/surviving spouse of an active member/veteran? Yes ___ No ___
Email Address: _________________________________________________________________________
Preferred Mailing Address: Home _____ Business _____
Home Address: _________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Home Phone: _________________________________________________________________________
Business Address: _________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Business Phone: _________________________________________________________________________
Psychologist Licensure Application
Pg. 2 of 6
v2; Revised 4/15/2021
3. EPPP – National Examination
EPPP Part-1
EPPP Part-2
Have you completed the EPPP Part-1? Yes___ No___ Have you completed the EPPP Part-2? Yes___ No___
Raw Score Earned: _____________________ Raw Score Earned: _____________________
Form Number, if known: _______________________ Form Number, if known: _______________________
Place Taken / Jurisdiction:
_______________________________________________
Place Taken / Jurisdiction:
_______________________________________________
Date Taken: ___________________________________ Date Taken: ___________________________________
4. APA-Accreditation
Was your graduate program accredited by the American
Psychological Association (APA) at the time of graduation? Yes ____ No ____
5. Licensing History
1. State / Jurisdiction ____________________________ License Type: _____________________
Date Acquired: ______________ License End Date (if applicable): ______________________
2. State / Jurisdiction ____________________________ License Type: _____________________
Date Acquired: ______________ License End Date (if applicable): ______________________
3. State / Jurisdiction ____________________________ License Type: _____________________
Date Acquired: ______________ License End Date (if applicable): ______________________
If licensed as a psychologist in additional states/jurisdictions, please list jurisdictions below:
__________________________________________________________________________________
6. Personal / Professional Conduct History
YES
NO
a) Is there currently or has there ever been any investigation or action taken against you
for any ethical, moral, legal or malpractice action?
b) Have you ever been found guilty, convicted, or held liable in any moral, ethical, legal, or
malpractice action?
c) Have you ever had a professional license or certificate denied, restricted, suspended or
revoked in any jurisdiction for any profession?
d) Have you ever relinquished responsibilities, let your license lapse, resigned a position, or
been fired due to an action pending or threatened?
Psychologist Licensure Application
Pg. 3 of 6
v2; Revised 4/15/2021
YES
NO
e) Have you ever resigned or been terminated from a professional organization or
surrendered a license while a complaint against you was being investigated or pending?
f) Have you ever been notified by any state, territory, district, country, U.S. government
agency, or state certification/licensing board of any complaint filed against you relative to
the practice of psychotherapy and/or assessment (including, but not limited to, any
allegations currently pending)?
g) Have you ever been convicted of, or pled guilty or nolo contendere, to a violation of any
federal or state statute, or any city or county ordinance, or any law of a foreign country?
(This includes misdemeanors and felonies and includes convictions subsequently
dismissed and deferred judgments. Exclude minor traffic violations only.)
h) Are you subject to a court order for the support of one or more children and not in
compliance with the order or with a repayment plan approved by the public agency
authorized to enforce the order?
i) Are you required to register as a sex offender?
j) Have you ever been suspended, disqualified, censured, or disciplined as a member of any
professional organization?
k) Have you ever been dismissed from or asked to resign from any education, training, or
employment due to negligence, professional misconduct or academic dishonesty?
l) Have you ever been subject to review and/or action by the ethics committee of any
organization?
Explain any “Yes” answers below. Attach a separate sheet if necessary.
7. Check any that apply:
___ I am licensed in at least one of the following states: Arkansas, Georgia, Hawaii, Kansas, Louisiana,
Mississippi, New Jersey, New York, Tennessee (Health Service Provider only), Texas, or Washington DC
___ I am licensed in at least one of the following states: Alaska, Colorado, Connecticut, Idaho, Iowa, Maine,
Maryland, Massachusetts, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Carolina,
North Dakota, Oklahoma (Health Service Psychologists only), Oregon, Pennsylvania, Rhode Island, South
Carolina, Washington, Wisconsin, or Wyoming
___ I have been continuously licensed for 20-years or more
___ I have a National Register of Health Science Psychologists Credential
___ I have an American Board of Professional Psychology (ABPP) Credential
___ I have a Certificate of Professional Qualification (CPQ) in Psychology
If none of the above apply, please skip to Section 14 (click here).
Psychologist Licensure Application
Pg. 4 of 6
v2; Revised 4/15/2021
8. Graduate Education
Highest Academic Degree Earned: _____________________________________________________________
Name of Graduate Program
University: _____________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
Title of Thesis / Dissertation: _____________________________________________________________
Additional Graduate Education Relevant to the Application (if applicable)
1. University: _____________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
Degree Earned (if any): __________________________________________________________________
2. University: _____________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
Degree Earned (if any): __________________________________________________________________
3. University: _____________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
Degree Earned (if any): __________________________________________________________________
9. Under-Graduate Education
1. University: ____________________________________________ Degree Earned: ________________
City, State, Zip: _________________________________________________________________________
Department / College: ___________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
2. University: ____________________________________________ Degree Earned: ________________
City, State, Zip: _________________________________________________________________________
Department / College: ___________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
3. University: ____________________________________________ Degree Earned: ________________
City, State, Zip: _________________________________________________________________________
Department / College: ___________________________________________________________________
Dates Attended: ________________________ Major Field: _____________________________________
Psychologist Licensure Application
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v2; Revised 4/15/2021
10. Pre-Doctoral Internship
1. Institution: _____________________________________________________________________________
Location (City, State, Zip): _________________________________________________________________
Supervisor: _____________________________________________________________________________
Dates: ______________________________ # Supervised Hours Accrued: _______________________
2. Institution: _____________________________________________________________________________
Location (City, State, Zip): _________________________________________________________________
Supervisor: _____________________________________________________________________________
Dates: ______________________________ # Supervised Hours Accrued: _______________________
11. Post-Doctoral Internship
1. Institution: _____________________________________________________________________________
Location (City, State, Zip): _________________________________________________________________
Supervisor: _____________________________________________________________________________
Dates: ______________________________ # Supervised Hours Accrued: _______________________
2. Institution: _____________________________________________________________________________
Location (City, State, Zip): _________________________________________________________________
Supervisor: _____________________________________________________________________________
Dates: ______________________________ # Supervised Hours Accrued: _______________________
12. Training/Experience Qualifying Applicant to Provide Specific Services to Certain Populations
1. Population: _____________________________________ Service: ____________________________
Training Experience: _____________________________________________________________________
2. Population: _____________________________________ Service: ____________________________
Training Experience: _____________________________________________________________________
13. Employment History (List employment history as a licensed psychologist)
1. Employer / Group / Agency: _______________________________________________________________
Location: ________________________________________ Begin/End Dates: _____________________
Was/Is this a full-time position? Yes _____ No _____
Was/Is there access to a licensed professional with 3 or more years’ experience? Yes _____ No _____
2. Employer / Group / Agency: _______________________________________________________________
Location: ________________________________________ Begin/End Dates: _____________________
Was/Is this a full-time position? Yes _____ No _____
Was/Is there access to a licensed professional with 3 or more years’ experience? Yes _____ No _____
Psychologist Licensure Application
Pg. 6 of 6
v2; Revised 4/15/2021
14. Final Steps
I agree that my name may be published as an applicant for licensure or registration in the State of Nevada. I
affirm, under penalty of perjury, that all of the information supplied herein is to the best of my knowledge
true, accurate and complete and that I have not withheld, misrepresented, or falsely stated any information
relevant to my training and experience or my fitness to practice psychology. I authorize the exchange of any
and all information concerning any and all complaints adjudicated, stipulated or pending against me with
licensing boards or professional associations. I understand such complaints may constitute grounds for
disciplinary action or denial of my application by the Board.
Signature: ___________________________________________________ Date: ____________
Upon receipt of this form and payment the Nevada Board of Psychological Examiners will evaluate your
credentials. If applicable, your information will be provided to the Association of State and Provincial
Psychology Boards for further processing through the Psychology Licensure Universal System (PLUS)
application. The application and supporting documents will be held in the ASPPB databank for future use of
applicants wishing to gain licensure in other states or provinces. ASPPB will contact applicants through the
email listed to complete the required application. Additional fees will apply. The Board office will communicate
any other requirements for licensure including a criminal background check and the Nevada State Examination.
When submitting this form, please include:
• $150 application fee, payable by check or money order to Nevada Board of Psychological Examiners
• Two passport-style photos, with one attached to the bottom left corner of this page.
Return to: State of Nevada Board of Psychological Examiners
4600 Kietzke Lane, B-116
Reno, NV 89502
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NEVADA STATE BOARD OF PSYCHOLOGICAL EXAMINERS Application for (State of Nevada, Department of Information Technology)

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Completed 21 December 2021

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