Problem Gambling Training Scholarship Application
Full Name
*
First Name
Middle Initial
Last Name
Applicant Type
*
Independent (Mental Health Professional with Clinical License)
Agency (LADC or Mental Health Practitioner working under Licensed Program)
Applicant Education Degree/Certification
*
Credential Type
*
LADC
LPCC
Mental Health Practitioner (under MN 245.462, Subd. 17)
Mental Health Professional (under MN 245.462, Subd. 18)
Other
If "Other", enter details:
Enter License/Certification Number:
*
Enter License/Certification Expiration Date:
*
Applicant Business/Agency Name
*
Business/Agency State Tax ID
Applicant Business Address
*
Street Address
Street Address Line 2
City / State
Zip Code
County
Applicant Email Address
*
example@example.com
Applicant Phone Number
*
Format: (000) 000-0000.
Business/Agency Phone Number
Format: (000) 000-0000.
Clinical Supervisor Name
First Name
Last Name
Clinical Supervisor Credentials
Clinical Supervisor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Supervisor Email
example@example.com
Date Planned to Enroll in Training Program
Date of Anticipated Completion of Training Program
I certify that the information provided on this form is true and correct. I will notify the Minnesota Alliance on Problem Gambling (MNAPG) of any additions or changes to this information, as necessary.
*
Yes
Signature
*
Application Date
-
Month
-
Day
Year
How did you hear about the training scholarship?
MNAPG Staff/Website
LinkedIn
Star Tribune
Dept. of Human Services
Colleague/Supervisor
Other
If "Other", please describe:
Submit
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