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Supervisor Registry Application
Have you practiced in your speciallty for at least 2000 clock hours over a minimum of 2 years following licensure?
Ethnic Origin/Gender (optional-for statistical purposes only) / please select one:
List Master's and Doctoral Degrees:
Ethics Verification
Please check the box next to the question if the anwer is yes.
If you checked the yes box next to any of the above questions, you must submit a complete, detailed explanation related to the response to the NASWGA Office Suite 125, 2300 Henderson Mill Road NE, Atlanta, Georgia  30345.
Applicant Acknowledgement & Agreement
I certify that all information I provided in this application, including supporting documentation, is accurate and complete to the best of my knowledge.  I recognize that NASWGA can only publish my name in the NASWGA Clinical Supervision Certificate Training - Taken and Passed Registry if the applicant has successfully completed the Clinical Supervision Certificate Program and Clinical Supervision Registry Application.  And, I have met the requirements for designation as a clinical supervisor set out in the rules of the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists (see rule 135-5.04(5)(e)). I consent to NASWGA including some or all of the information provided in this application in its Clinical Supervision Registry, and making that information publicly available ,
if my application is accepted.
I will notify NASWGA immediately if I am no longer qualified to provide supervision (for instance, if my license has been revoked, suspended, voluntarily terminated, expires or for any other reason becomes invalid).  If I have knowledge of any other changes concerning my responses in this application, I agree to report this to NASWGA in writing within 30 days.  I understand that if I become unqualified to provide supervision or any information provided is later determined to be false, NASWGA reserves the right to remove my listing from the Registry, and any fees paid by me shall not be refunded.
I agree to indemnify NASWGA and NASW, their employees, officers, board members and volunteers and hold them harmless from any liability arising in connection with my participation in the Clinical Supervision Registry or my relationship with any potential Supervisee who contacts me as a reult of my Registry listing.
*Failure to provide all required information will delay the processing of your application.
( point the mouse cursor on the line, hold the left mouse button down, and sign.)
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