FORM C

Use for: Request Temporary license

)or office use only Budget @ #.# )und @#AB @: 666666666 8: 666666666

TEXAS STATE BOARD OF SOCIAL WORKER EXAMINERS TEMPORARY LICENSE APPLICATION FORM
Name Mailing address: Street City, State, ip !"one No No Temporary license requested LMSW LBSW

#$ % am currently under application for regular licensure &es '$ % am su(mitting application )orm * at t"is time + &es

%f you c"ec,ed no, to (ot" of t"e pre-ious questions, do not continue$ &ou must (e under application for regular licensure to (e eligi(le for a temporary license$

Board Rules pertaining to temporary licensure: 781.311. Temporary License. (a) Prior to examination, an applicant for licensure may obtain a temporary license as a social wor er as lon! as t"e applicant meets all t"e re#uirements, wit" t"e exception of t"e examination, for t"e le$el of license sou!"t. (1) % person "ol&in! a temporary license must ta e t"e &esi!nate& examination wit"in six mont"s of issuance of t"e temporary license. (') T"e temporary license is $ali& until t"e results of t"e first #ualifyin! examination are ma&e a$ailable (i.e., t"e first examination ta en by t"e temporary licensee or t"e en& of t"e six mont"s from issuance of t"e license if t"e examination is not ta en, w"ic"e$er is earlier). (3) % person "ol&in! a temporary license must &isplay t"e license at t"e licensee(s place of business an& must use t"e appropriate license& title or initials followe& by t"e wor& )Temporary) in all professional use of t"e licensee(s name. (*) +"oul& t"e applicant ta e an& fail t"e exam, t"e temporary license is no lon!er $ali&. T"e applicant must cease an& &esist from t"e use of t"e temporary license an& title imme&iately. (,) +"oul& t"e applicant pass t"e exam t"e boar& will issue t"e license or specialty reco!nition in accor&ance wit" 781.3-,(!) of t"is title (relatin! to %pplication .or Licensure). (b) % person w"o faile& t"e examination an& is wit"out a $ali& temporary license may reta e t"e examination un&er 781.31' of t"is title (relatin! to /xamination 0e#uirement). (c) % temporary license will not be !rante& to an applicant w"o "as "el& a temporary license for t"e same license cate!ory wit"in t"e pre$ious fi$e years. (&) %n applicant for L1+2 or specialty reco!nition is not eli!ible for a temporary or pro$isional license. (e) %pplicants re#uestin! a temporary license must submit t"e application form an& temporary fee re#uire& by t"e boar&. .$ % "a-e read and understood t"e a(o-e rule$ % also understand t"at may not (egin t"e formal super-ision process for credit to/ard ad-anced licensure or specialty recognition until a regular license is issued$ &es No 0&ou s"ould maintain your certificate of completion$1 2$ % "a-e completed t"e TSBSW3 4urisprudence e5amination &es No 0&ou s"ould maintain your certificate of completion$1 % am requesting a temporary license$ 666666666666666666666666666666 Signature Return form /it" fee 08.91 to: 666666666666666 7ate Te5as State Board of Social Wor,er 35aminers !: Bo5 #'#;< Capital Station *ustin, T= <><##?'#;<
With few exception ! "o# h$%e $ &i'ht to &e(#e t $n) *e info&+e) $*o#t info&+$tion th$t the St$te of Tex$ co,,ect $*o#t "o#- Yo# $&e entit,e) to &ecei%e $n) &e%iew the info&+$tion #pon &e(#e t- Yo# $, o h$%e the &i'ht to $ . the t$te $'enc" to co&&ect $n" info&+$tion th$t i )ete&+ine) to *e inco&&ect- Mo t info&+$tion #*+itte) to the *o$&) i #*/ect to )i c,o #&e #n)e& the P#*,ic Info&+$tion Act- 0Refe&ence1 2o%e&n+ent Co)e! Section 344-546! 344-547! 338-557 $n) 338-559:

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