37A 301A Form PDF Details

Did you know that the 37A 301A form is used to notify the IRS of a sale or exchange of property? If you're not familiar with this form, don't worry! In this blog post, we'll go over everything you need to know about the 37A 301A form. We'll also provide some tips on how to complete the form correctly.

In order to look at a few specific details when it comes to the file you are going to use, here is the data you can read before submitting the 37a 301a form.

QuestionAnswer
Form Name37A 301A Form
Form Length2 pages
Fillable?Yes
Fillable fields52
Avg. time to fill out10 min 58 sec
Other namesform experience verification, bbs verification form, experience verification 37a, bbs experience verification

Form Preview Example

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY

Governor Edmund G. Brown Jr.

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830 TTY: (800) 326-2297

www.bbs.ca.gov

LICENSED MARRIAGE AND FAMILY THERAPIST

IN-STATE EXPERIENCE VERIFICATION

OPTION 1 – NEW STREAMLINED METHOD

This form is to be completed by the applicant’s California supervisor and submitted by the applicant with his or her Application for Licensure and Examination. All information on this form is subject to verification.

Use this “Option 1” form to report hours under the NEW streamlined method

Use separate forms for pre-degree and post-degree experience

Use separate forms for each supervisor and each employment setting

Ensure that the form is complete and correct prior to signing

Provide an original signature and have the supervisor initial any changes

Do not submit Weekly Summary forms unless specifically requested

The hours reported on this form were earned (mark one):

Pre-Degree

Post-Degree

APPLICANT NAME:

Last

First

Middle

Intern Number

IMF

SUPERVISOR INFORMATION:

Supervisor’s Last Name

First

Middle

Business Phone

Email Address (OPTIONAL)

License Type

License Number

State

Date First Licensed

Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the

entire period of supervision? D N/A D No D Yes: Date Certified: __________ Cert. #: ____________

LPCCs: Did you meet the qualifications to treat couples and families during the entire period of supervision, as

specified in California law? D N/A D No D Yes: Date you met the qualifications: ______________

APPLICANT’S EMPLOYER INFORMATION:

Name of Applicant’s Employer

Business Phone

Address

Number and Street

City

State

Zip Code

37A-301 (Revised 04/2017)

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Applicant: Last

First

Middle

EMPLOYER INFORMATION (continued):

1.Was this experience gained in a setting that lawfully and regularly provides mental health counseling or psychotherapy?

2.Was this experience gained in a private practice setting?

3.Was this experience gained in a setting that provided oversight to ensure that the applicant’s work meets the experience and supervision requirements and is within the scope of practice?

4.For hours gained as an Intern ONLY: Was the applicant receiving pay?

If YES, attach a copy of the applicant’s W-2 statement for each year experience is claimed. If a W-2 has not yet been issued for this year, attach a copy of the current paystub. If applicant volunteered, submit a letter from the employer verifying volunteer status.

D Yes D No

D Yes D No D Yes D No

D Yes D No

D (preN/A-degree

experience)

EXPERIENCE INFORMATION:

 

1. Dates of experience being claimed:

 

From: __________________

To: _____________________

 

 

 

mm/dd/yyyy

 

mm/dd/yyyy

2. How many weeks of supervised experience are being claimed? __________ weeks

 

 

 

 

 

 

 

 

3. Hours of Experience:

 

 

 

 

 

Logged Hours

 

 

 

 

 

 

 

 

a. Total Direct Counseling Experience

(Minimum 1,750 hours)

 

 

 

 

 

 

 

 

 

 

 

 

• Of the above hours, how many were gained diagnosing and treating

 

 

 

Couples, Families and Children? (Minimum 500 of the 1,750 hours)

 

 

 

 

 

 

b. Total Non-Clinical Experience (Maximum 1,250 hours)

 

 

 

 

 

 

 

 

 

 

 

• Of the above hours, how many were Face-to-Face

Hours Per Week

Logged Hours

 

Supervision?

 

 

 

 

 

 

 

 

 

 

Individual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group (group contained no more than 8 persons)

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Knowingly providing false information or omitting pertinent information may be grounds for denial of the application. The Board may take disciplinary action on a licensee who helps an applicant obtain a license by fraud, deceit or misrepresentation.

Signature of Supervisor: _______________________________________

Date: ______________

37A-301 (Revised 04/2017)

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How to Edit 37A 301A Form Online for Free

It's super easy to prepare the experience verification 37a. Our PDF editor was created to be assist you to prepare any form efficiently. These are the steps to follow:

Step 1: On this web page, hit the orange "Get form now" button.

Step 2: It's now possible to modify your experience verification 37a. This multifunctional toolbar will allow you to add, erase, adapt, and highlight content as well as carry out other sorts of commands.

Create the following parts to create the template:

portion of gaps in ca bbs form experience

Fill in the APPLICANTNAMELast, First, Middle, InternNumberIMF, First, Middle, BusinessPhone, EmailAddressOPTIONAL, LicenseType, LicenseNumber, State, DateFirstLicensed, entireperiodofsupervision, YesDateyoumetthequalifications, and specifiedinCalifornialaw fields with any information that is required by the system.

step 2 to finishing ca bbs form experience

You will be required to enter the details to let the software prepare the box BusinessPhone, Address, NumberandStreet, City, State, ZipCode, and ARevised.

BusinessPhone, Address, NumberandStreet, City, State, ZipCode, and ARevised in ca bbs form experience

For field Applicant, Last, First, Middle, EMPLOYERINFORMATIONcontinued, healthcounselingorpsychotherapy, Yes, Yes, Yes, DYesDNApredegreeexperience, and EXPERIENCEINFORMATION, indicate the rights and obligations.

Completing ca bbs form experience part 4

Finalize by reading these sections and filling them out correspondingly: EXPERIENCEINFORMATION, Datesofexperiencebeingclaimed, From, mmddyyyy, mmddyyyy, HoursofExperience, LoggedHours, and HoursPerWeekLoggedHours.

ca bbs form experience EXPERIENCEINFORMATION, Datesofexperiencebeingclaimed, From, mmddyyyy, mmddyyyy, HoursofExperience, LoggedHours, and HoursPerWeekLoggedHours fields to fill

Step 3: Click the "Done" button. Now it's possible to export your PDF document to your electronic device. As well as that, it is possible to deliver it via electronic mail.

Step 4: It is better to create copies of the file. You can rest assured that we won't distribute or view your particulars.

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