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Update Licensure Information

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
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:

 

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