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Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. List all experience that you wish to be evaluated for licensure. Your experience must be listed in chronological order beginning with your first employment for which experience is being claimed, and include firm name, name of endorser, beginning and ending dates, and total time claimed for each endorser. Be sure to sign and date item 6.

You must also complete a separate Form 4A for every employer you list on this form. Your application will not be reviewed by the Board until a Form 4A for every employer listed has been received.

When an endorsement does not lend credibility to your experience, it may be discounted at the judgement of the Board. A Form 4A that is not endorsed will not receive any credit towards licensure.