Form 4A - Identification of Supervisor and Setting

This form should be submitted at the beginning of your supervised experience. When the Application for Licensure (Form 1), the fee, Certification of Professional Education Form (Form 2), and Identification of Supervisor and Setting Form are received and approved, you will receive verification (Form 6).

If application is not made until after the supervised experience begins, or at the end of the experience, it is still necessary to complete and submit this form.

• Section I: Complete this section and ask your employer and/or supervisor to complete Section II, Part A.
• Section II: Complete parts B, C and D of this section with your employer and/or supervisor and then return the entire form directly to the Office of the Professions at the address at the end of the form.