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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 2 of 2 Date. 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 Address Number and...

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