TO BE COMPLETED BY THE APPLICANT. I Mr./Mrs./Miss ………………………………………………………………MNO…………………...
TO BE COMPLETED BY THE APPLICANT. I was granted a license as described above and request that verification of that license and supervised experience approved by your board, as applicable, be submitted to the Texas State Board of Social Worker Examiners. You are hereby authorized to release any information in your files, favorable or otherwise, directly to this state's Social Work Board. Your early attention is appreciated. Signature Date PART II-TO BE COMPLETED BY THE STATE BOARD VERIFYING LICENSURE (Please complete this form and return it to the address indicated. Attach copies of any verification of supervision received after applicant received their MSW.) Name of Licensee Licensure Level License No. Date Issued Please Verify All Requirements Met in Your Jurisdiction Education: BSW from CSWE Accredited School MSW from CSWE Accredited School Experience: # Months Post LMSW Clinical Experience # Hours of face to face supervision # Hours clinical experience # Months Post LMSW Non-clinical Experience # Hours of face to face supervision # Hours non-clinical experience Exam Taken ASWB or ASI (Only the ASWB or ASI will be accepted) Other Date Exam Passed Level Exam Taken If no Exam score is on file, how was licensure obtained? Grandfathered Endorsement; If endorsement, what state? License Current? Expiration Date Yes No Complaints and/or Disciplinary Action Yes* No *Explain Complaints or Disciplinary Actions (please enclose a copy of any board orders): Signature of person completing form Date Insert Board Seal Here / Printed name of person completing form / phone number Title of person completing form Mail to: TEXAS STATE BOARD OF SOCIAL WORKER EXAMINERS P.O. Box 149347, Mail Code 1982 Xxxxxx, Xxxxx 00000-0000 0-000-000-0000 0-000-000-0000 (TEXAS ONLY) With few exceptions, you have a right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. Most information submitted to the board is subject to disclosure under the Public Information Act. (Reference: Government Code, Sections 522.021, 522.023, 559.003 and 559.004) Revised 10/13/07 FORM III TEXAS STATE BOARD OF SOCIAL WORKER EXAMINERS Clinical Supervision Plan *** Be sure to complete ALL portions of this form. Do not submit if incomplete. ***
TO BE COMPLETED BY THE APPLICANT. I understand that: ⬜ This is a full-time Fellowship. Fellows are required to work full-time on their Xxxxxx Challenge project; ⬜ Fellowship activities should be oriented around a final product(s). The product(s) must be made available in English and be open source; ⬜ Attendance of at least one in-person convening and monthly online Progress Update and Co-learning calls (amounting to 8 hours each month) are compulsory; ⬜ Fellows should not be in receipt of other forms of income or Fellowships during their Fellowship year without agreement from Xxxxxx Challenge Director. THE APPLICANT Name, Signature and Date:…………………………………………………………………………….
TO BE COMPLETED BY THE APPLICANT. Full Name ……………………………………………..…..….…….I.D/Passport No… (Attach Copy) KRA Pin ………………….…………….(Attach Copy) Membership Number…………. Payroll Number………….. Age……… Physical Address (Home/Estate/Street/House Number) ………………..………………………………………. P.O. Box ………..…..… Code …………… E-mail …………………………………. Telephone (Private)…..……...… B. LOAN DETAILS Amount in figure:……………………Amount in words ………………………………………………… …… Repayment period (Maximum 36 Months). I have identified the item (s) at shop.
TO BE COMPLETED BY THE APPLICANT. I Mr./Mrs./Miss I.D/Passport No. (Attach Copy) Hereby apply for a loan of Kshs ………………..……………………… Amount in words ……………………………………………………………………………………………. To be repaid in Months (Maximum 24 Months) I authorize my employer to recover the loan granted to me from my monthly salary in installments which may be determined by management committee plus interest at the rate of 1.125% on the reducing balance. I hereby attach my most current stamped pay slip and a copy of ID Signature (Applicant)………………………………………………………. Date………………............................ N/B: FORGERY IS A CRIMINAL OFFENCE
TO BE COMPLETED BY THE APPLICANT. I understand that it is my duty (within the boundaries of my role), to safeguard the children, young people and vulnerable adults with whom I have contact. I know what action to take in cases of suspected or alleged abuse or if I am concerned. Signed (Volunteer) …………………………………………………………….. Date ……………………………………………. Signed (On behalf of the parish) ……………………………………….. Date …………………………………………… NB - Two copies of this form should be made. One copy should be given to the individual and the other retained by the person responsible for the appointment.
