Apply to join the Social Work Registry

Identification and contact information

Name*

First Middle initital Last

Other names

Last 4 digits of your Social Security number

Gender

Email*

Date of birth*

MM

DD

YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number

Education information

Degree*

Graduation date*

Major*

College/School Name*

School code

School codes

Do you have other (social work related) education to add?

Yes
No

Degree

Graduation date

Major

College/School Name

Licensure information

Licensure designation (eg., - LCSW, LICSW, etc.)

State/Province

License number

Basis for license

Examination
Endorsement
Reciprocity
Grandfathering

Do you have an additional license?

Yes
No

Licensure designation (ie. - LCSW, MSW, etc.)

State/Province

License number

Basis for license

Examination
Endorsement
Reciprocity
Grandfathering

Supervision information

Supervisor's name

Supervisor's email

Supervisor's phone number

Supervisor's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have another supervisor to add?

Yes
No

Supervisor's name

Supervisor's Email

Supervisor's phone number

Supervisor's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supporting documents

If you have legal documentation regarding a name change (e.g., marriage certificate, divorce decree, legal name change) please upload it with this form.

File

ASWB Registry: New application

Identification and contact information

Education information

Licensure information

Supervision information

Supporting documents