NBOP Revised Application

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Acknowledgement* This field is required.Any omissions, false or misleading information in, or connected with, this application, its attachments or other communications with the Board may be cause for denial or revocation of licensure.
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Registration Applicants

Psychological Trainee. A person may register with the Board as a psychological trainee who:

Is in a doctoral training program in psychology at an accredited educational institution approved by the Board or in doctorate-level training from an accredited educational institution deemed equivalent by the Board in both subject matter and extent of training; and

Wishes to perform professional activities or services under the supervision of a psychologist.

Psychological Intern. A person may register with the Board as a psychological intern who:

Is in a doctoral training program in psychology at an accredited educational institution approved by the Board or in doctorate-level training from an accredited educational institution deemed equivalent by the Board in both subject matter and extent of training; and

Wishes to engage in a predoctoral internship pursuant to the requirements of the training program

Psychological Assistant. A person who wishes to obtain any postdoctoral supervised experience that is required for licensure as a psychologist must register with the Board as a psychological assistant.

All applicants for registration are subject to a criminal background check.

If you have secured a supervisor, you will be asked for the name and email address, which will constitute permission for the Board to communicate with the supervisor related to the registration process.
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Applying as:* This field is required.Select Psychological Assistant, Psychological Intern, or Psychological Trainee from the list below. For additional information, visit https://psyexam.nv.gov/Licensing/.
Psychological Assistant
Psychological Intern
Psychological Trainee
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SupervisorBy providing the information below, you are allowing the Board to communicate with your supervisor regarding registration requirements.
Have you secured a supervisor? Yes / No
If Yes, SUPERVISOR'S NAME
Supervisor's email address
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Degree* This field is required.Select appropriate degree (Ph.D., Psy.D., or Ed.D.) that you have obtained or will be obtaining from the list below.
Ph.D.
Psy.D.
Ed.D.
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Degree Program* This field is required.Select degree program from the list below. ** Please note: Applicants who have or will obtain a doctoral degree in a program other than Clinical, Counseling, or School Psychology may be subject to an equivalency evaluation.
Clinical
Counseling
School
Other**
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Full Name
Please Select
Please Select
Dr.
Miss
Ms.
Mrs.
Mr.
Salutation
First
Middle
Maiden (if applicable)
Last
8
General Information* This field is required.
Social Security Number
Are you a U.S. Citizen?
Place of Birth
Date of Birth
Preferred Pronouns
9
U.S. Armed ServicesAre you
an active member or veteran of the U.S. Armed Forces?
the spouse of an active member or veteran of the U.S. Armed Forces?
10
Email Address
example@example.com
11
Preferred Mailing Address:* This field is required.
Home
Business
12
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Home Phone Number
Area Code
Phone Number
14
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Business Phone Number
Area Code
Phone Number
16
EPPP Part-1
Please Select
Please Select
Yes
No
Have you completed the EPPP Part-1?
Place Exam Taken / Jurisdiction
Date of Exam
Score
17
EPPP Part-2
Please Select
Please Select
Yes
No
Have you completed the EPPP Part-2?
Place Exam Taken / Jurisdiction
Date of Exam
Score
18
Was your graduate program accredited by the American Psychological Association (APA) at the time of graduation?* This field is required.Or, will it be APA-accredited when you graduate?
YESNO
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Under-Graduate Education
University
City, State, Zip
Dates Attended
Department/College
Degree Earned (if any)
Major
20
Under-Graduate Education
University
City, State, Zip
Dates Attended
Department/College
Degree Earned (if any)
Major
21
Highest Academic Degree Earned
22
Graduate Program Information
University
Name of Graduate Program
City, State, Zip
Dates Attended
Major Field
23
Additional Graduate Education Relevant to this ApplicationComplete if applicable
University
Name of Graduate Program
City, State, Zip
Dates Attended
Major Field
Degree Earned (if any)
24
Pre-Doctoral Internship
Institution
Supervisor
Location City, State, Zip
Dates
# internship hours
# hours supervision
25
Pre-Doctoral Internship Complete if a second location was needed.
Institution
Supervisor
Location City, State, Zip
Dates
# internship hours
# supervised hours
26
Post-Doctoral Information (if applicable)
Institution
Supervisor
Location City, State, Zip
Dates
# of Training Hours Accrued
27
Licensing, Certification, or Registration History (1)
State / Jurisdiction
Date Acquired
License, Certification, or Registration Type/Title
End date (if applicable)
28
Licensing, Certification, or Registration History (2, if applicable)
State / Jurisdiction
Date Acquired
License, Certification, or Registration Type/Title
End date (if applicable)
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Licensing, Certification, or Registration History (3, if applicable)
State / Jurisdiction
Date Acquired
License, Certification, or Registration Type/Title
End date (if applicable)
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If licensed as a psychologist in additional states, please list below
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Check any that apply:
I am licensed as a PSYCHOLOGIST in at least one of the following states: Arkansas, Georgia, Hawaii, Kansas, Louisiana, Mississippi, New Jersey, New York, Tennessee (Health Service Provider only), Texas, or Washington DC
I am licensed as a PSYCHOLOGIST in at least one of the following states: Alaska, Colorado, Connecticut, Idaho, Iowa, Maine, Maryland, Massachusetts, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Oklahoma (Health Service Psychologists only), Oregon, Pennsylvania, Rhode Island, South Carolina, Washington, Wisconsin, or Wyoming
I have been continuously licensed as a PSYCHOLOGIST for 20-years or more
I have a National Register of Health Science Psychologists Credential
I have an ABPP (American Board of Professional Psychology) Credential
I have a Certificate of Professional Qualification in Psychology
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Additional Graduate Education Relevant to this ApplicationComplete if needed.
University
City, State, Zip
Dates
Major Field
Degree Earned (if any)
33
Additional Graduate Education Relevant to this ApplicationComplete if needed.
University
City, State, Zip
Dates
Major Field
Degree Earned (if any)
34
Under-Graduate EducationComplete, if needed
University
City, State, Zip
Dates
Department/College
Degree Earned (if any)
Major
35
Under-Graduate EducationComplete, if needed
University
City, State, Zip
Dates
Department/College
Degree Earned (if any)
Major
36
Under-Graduate EducationComplete, if needed
University
City, State, Zip
Dates
Department/College
Degree Earned (if any)
Major
37
Post-Doctoral InformationComplete, if needed for additional information
Institution
Supervisor
Location City, State, Zip
Dates
# of Training Hours Accrued
38
Training / Experience Qualifying Applicant to Provide Specific Services to Certain Populations
1. Population
Service
Training Experience
2. Population
Service
Training Experience
39
Employment HistoryList employment history as a licensed psychologist
Employer, Group, Agency
Location
Was/Is this a full-time position?
Begin / End Dates
40
Employment HistoryList employment history as a licensed psychologist
Employer, Group, Agency
Location
Was/Is this a full-time position?
Begin / End Dates
41
Is there currently or has there ever been any investigation or action taken against you for any ethical, moral, legal or malpractice action?
YESNO
42
Have you ever pled guilty or nolo contendere or been found guilty, convicted, or held liable in any moral, ethical, legal, or malpractice action?
YESNO
43
Have you ever had a professional license, registration, certification, or credential denied, restricted, suspended, censured, or revoked in any jurisdiction for any profession?
YESNO
44
Have you ever relinquished responsibilities, let your license lapse, resigned a position, or been fired due to an action pending or threatened?
YESNO
45
Have you ever resigned or been terminated from a professional organization or surrendered a license while a complaint against you was being investigated or pending?
YESNO
46
Have you ever been notified by any state, territory, district, country, U.S. government agency, or state certification/licensing board of any complaint filed against you relative to the practice of psychotherapy and/or assessment (including, but not limited to, any allegations currently pending)?
YESNO
47
Have you ever been convicted of, or pled guilty or nolo contendere, to a violation of any federal or state statute, or any city or county ordinance, or any law of a foreign country? (This includes misdemeanors and felonies and includes convictions subsequently dismissed and deferred judgments. Exclude minor traffic violations only.)
YESNO
48
Are you subject to a court order for the support of one or more children and not in compliance with the order or with a repayment plan approved by the public agency authorized to enforce the order?
YESNO
49
Are you required to register as a sex offender?
YESNO
50
Have you ever been suspended, disqualified, censured or disciplined as a member of any professional organization?
YESNO
51
Have you ever been dismissed from or asked to resign from any education, training, or employment due to negligence, professional misconduct or academic dishonesty?
YESNO
52
Have you ever been subject to review and/or action by the ethics committee of any professional organization?
YESNO
53
Explain any "Yes" answers here.
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SignatureI agree that my name may be published as an applicant for licensure or registration in the State of Nevada. I affirm, under penalty of perjury, that all of the information supplied herein is to the best of my knowledge true, accurate and complete and that I have not withheld, misrepresented, or falsely stated any information relevant to my training and experience or my fitness to practice psychology. I authorize the exchange of any and all information concerning any and all complaints adjudicated, stipulated or pending against me with licensing boards or professional associations. I understand such complaints may constitute grounds for disciplinary action or denial of my application by the Board.
Clear
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APPLICATION FEE:

The application fee is $150.00. An additional fee of $5.10 will be added to cover the administrative costs assessed by PayPal. If you would prefer to pay via check or money order, mail the application and fee to: Nevada Board of Psychological Examiners, 3080 South Durango Drive, Suite 102, Las Vegas, NV 89117.
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Upon receipt of this form and payment the Nevada Board of Psychological Examiners will evaluate your credentials. If applicable, your information will be provided to the Association of State and Provincial Psychology Boards for further processing through the Psychology Licensure Universal System (PLUS) application. The application and supporting documents will be held in the ASPPB databank for future use of applicants wishing to gain licensure in other states or provinces. ASPPB will contact applicants through the email listed to complete the required application. Additional fees will apply. The Board office will communicate any other requirements for licensure including a criminal background check and the Nevada State Examination.
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Registration Applicants