Please enter your Social Work Registry Number and enter any data that has changed since your last udpate. If you have earned more than one additional license, please complete and submit this form for each license.
The issuing jurisdiction will be contacted toverify the information you provide.
REGISTRY NUMBER:
Full Name:
NEW License Information:
License
e.g., Licensed Clinical Social Worker, Licensed Social Worker, etc.
License Number
Issuing State or Province
State/Province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Labrador Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshier New Jersey New Mexico New York Newfoundland North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Date Issued
Expiration Date
Current Satus:
Current/Active Expired Revoked/Suspended Under Investigation Other--Please Specify:
Basis for License:
Examination Endorsement Reciprocity Grandparenting Other--Please Specify:
