{"content":[{"text":"Mississippi \n State Board of Examiners for Social Workers and Marriage and Family Therapists \n P.O. Box 4508, Jackson, MS 39296-4508 \n (601) 987-6806/ Fax: 601-987-6808","bbox":{"left":0.200425,"top":0.054214,"width":0.5994229999999999,"height":0.067399}},{"text":"Application for Certification as a LCSW Supervisor","bbox":{"left":0.058824,"top":0.147449,"width":0.45280699999999996,"height":0.020863999999999994}},{"text":"Please Type or Print","bbox":{"left":0.058824,"top":0.182298,"width":0.181039,"height":0.020863999999999994}},{"text":"I. Personal Information LCSW License NO.___________ Last 4 SSN ____________ \n Name as appears on your LCSW license ___________________________________________ \n Name if different from above ___________________________ Date of Birth ______________ \n License expiration date: _____________________ Tel. ( )_____________________ \n Current Mailing Address ________________________________________________________ \n ________________________________________________________ \n Current Employer ___________________________________ Tel. ( )__________________ \n Address _____________________________________________________________________","bbox":{"left":0.058824,"top":0.217222,"width":0.798859,"height":0.20388599999999998}},{"text":"II. Board Approved LCSW Supervisor Training","bbox":{"left":0.058824,"top":0.472942,"width":0.412176,"height":0.020863999999999994}},{"text":"Completion of a Board approved supervision course for a minimum of sixteen hours (16) hours is required. \n All supervision training must be approved by the Board in order to be considered for this purpose. \n Supervision trainers must be an approved LCSW supervisor.","bbox":{"left":0.058824,"top":0.507715,"width":0.880319,"height":0.055690999999999935}},{"text":"Declaration of Applicant: I the undersigned do hereby apply for certification as a qualified supervisor for \n applicants seeking the supervisory process leading to licensure as a Licensed Certified Social Worker. I \n declare that I am willing to abide by the rules and regulations of a supervisor as defined in the book of Rules \n and Regulations Regarding the Licensure of Social Workers and Marriage and Family Therapists and within \n the boundaries of the laws of the State of Mississippi of the United States.","bbox":{"left":0.058824,"top":0.577437,"width":0.883055,"height":0.09051500000000001}},{"text":"Signed____________________________________________ Date ____________________","bbox":{"left":0.058824,"top":0.682134,"width":0.791408,"height":0.020970000000000044}},{"text":"Instructions: Complete the LCSW Test and Application for Certification as a LCSW Supervisor, and mail \n everything in together to the Board’s address listed above with an $80.00 money order or cashier’s check.","bbox":{"left":0.058824,"top":0.725619,"width":0.883143,"height":0.038242}},{"text":"___________________________________________________________________________________________________ \n FOR BOARD USE ONLY \n APPROVE _____ NOT APPROVED ______ DATE: ____________","bbox":{"left":0.070392,"top":0.850155,"width":0.859228,"height":0.04645300000000008}},{"text":"ASSIGNED SUPERVISOR ID No. __________________","bbox":{"left":0.301601,"top":0.908269,"width":0.39693599999999996,"height":0.017279000000000044}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}