Professional Conduct and Applicant Certification Form

PROFESSIONAL CONDUCT AND APPLICANT CERTIFICATION FORM

This form may also be completed and submitted online:

For Masters Applicants: PROFESSIONAL CONDUCT AND APPLICANT CERTIFICATION FORM-For Masters Applicants

For Doctoral Applicants: Professional Conduct and Applicant Certification Form for Doctoral Trainees

PROFESSIONAL CONDUCT

Please answer ALL of the following questions with "YES" or "NO": (If yes, please elaborate)

1. Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor, educational or training institution or place of employment?

2. Are there any complaints currently pending against you before any of the above bodies?

3. Has there ever been a decision in a civil suit rendered against you relative to your professional work, or is any such action pending?

4. Have you ever been suspended, terminated, or asked to resign by a graduate or training program, practicum site, or employer?

5. Have you ever, in your lifetime, been convicted of an offense against the law other than a minor traffic violation?

6. Have you ever, in your lifetime, been convicted of a felony?

APPLICATION CERTIFICATION

I certify that all of the information submitted by me in this application is true to the best of my knowledge and belief. I understand that any significant misstatement in, or omission from, this application may be cause for denial of selection as an trainee or dismissal from a trainee position. I authorize the Counseling Center to consult with persons and institutions with which I have been associated who may have information bearing on my professional competence, character, and ethical qualifications now or in the future. I release from liability all Counseling Center staff for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I also release from liability all individuals and organizations who provide information to the Counseling Center in good faith and without malice concerning my professional competence, ethics, character, and other qualifications now or in the future.

If I am accepted and become a trainee at the Counseling Center, I expressly agree to comply fully with the the Ethical Principles of Psychologists and Code of Conduct and the General Guidelines for Providers of Psychological Services of the American Psychological Association. I also agree to comply with all applicable state, provincial and federal laws, all of the Rules and Code of Conduct of the State Licensing Board of Psychology, and the rules of the institution and the Counseling Center in which I am a Trainee.

I understand and agree that, as an applicant for the Counseling Center program, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications.

Applicant's Signature: Date: