Professional counselor license

Mixed

Department of Commerce, Community, and Economic Development · Division of Corporations, Business and Professional Licensing · 08-4910 (Rev. 08/21/2026) · AS 08.29 and 12 AAC 62

Personal information

Form 08-4910 Part II

Full legal name

No other names used

Other names used (maiden, nicknames, aliases) (optional)

Mailing address

Primary state of residence

Contact phone

Date of birth

Email address

U.S. Social Security Number provided (AS 08.01.060)

Provided

Request for exemption attached