[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-305383-105":53,"doc-detail-305383-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","lcsw-short-form-application-three-part-document-part-i-affirmation-and-signature","LCSW Short-Form Application - Three-Part Document - Part I - Affirmation and Signature","","LCSW Short-Form Application (Three-Part Document) collects attestation, supervision, examination, and continuing-education details needed for North Carolina LCSW licensure for eligible LCSW Associate licensees. It requires certification that the applicant completed 3,000 hours of paid supervised clinical experience, at least 100 hours of supervision, and passed the ASWB clinical-level exam, plus 40 CE hours within a two-year period with ethics requirements. The form includes signature blocks, supervisor recommendations, a continuing education log, and a public notice statement certification.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/lcsw-short-form-application-three-part-document-part-i-affirmation-and-signature/305383/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/lcsw-short-form-application-three-part-document-part-i-affirmation-and-signature/305383.png","ImageObject",442,249,{"name":88,"@type":89},"Marry","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-11","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"Who is eligible to use this LCSW short-form application?","Question",{"text":109,"@type":110},"It is intended only for LCSW Associate licensees who have completed all requirements for LCSW licensure.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What minimum supervised clinical experience and supervision hours are required?",{"text":114,"@type":110},"The applicant must document 3,000 hours of paid supervised clinical experience over a period no less than 2 years and no more than 6 years, and must complete a minimum of 100 hours of clinical supervision.",{"name":116,"@type":107,"acceptedAnswer":117},"What continuing education hours are required, and what ethics requirement applies?",{"text":118,"@type":110},"A minimum of 40 CE hours is required for a full two years, including at least 4 hours focused on ethics in social work practice.",{"name":120,"@type":107,"acceptedAnswer":121},"What must be included regarding the public notice statement certification?",{"text":122,"@type":110},"The applicant must certify that they read and understand the public notice statement maintained by the N.C. Industrial Commission and disclose whether they have been investigated for employee misclassification within the past twelve months or since the last renewal.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},305383,1791125167,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":144,"read_time":9},5909892079670,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","LCSW SHORT-FORM APPLICATION  \n(Three-Part Document)  \nPART I: Affirmation and Signature  \nNote: This document to be used only by LCSW Associate licensees who have completed all requirements for LCSW licensure. Please review, with your clinical supervisor, your six-month review submissions submitted to the Board to ensure all requirements have been met (initial below):  \n1.   3,000 hours of paid supervised clinical experience in a period no less than 2 years or more than 6 years. You must document two years (24 months) of supervised clinical practice to qualify for the LCSW license. Insert start date of supervised clinical practice reported on first six-month review form:   ;  \n2.   Minimum of 100 hours of clinical supervision. Insert total number of clinical supervision hours completed Individual   Group  (include final six-month Review Form to document all supervised clinical practice and supervision obtained since your last submission);  \n3.   Passed the ASWB Clinical level exam. Insert date of passing exam   ;  \n4.   Documentation of continuing education at the required rate of 40 hours within a two-year licensing period, with at least 4 hours of continuing education focused on ethics in social work practice. [Refer to the Board’s Position Statement on Continuing Education for information on pro-rated continuing education for licensure periods less than two years.]  \n** Enclose a non-refundable fee of $145.00 (certified check, money order, or cashier’s check submitted within six  \nmonths of issuance) payable to NCSWCLB.**   \n  I affirm that I have completed the necessary requirements to obtain licensure in North Carolina as a Licensed Clinical Social Worker and that the information provided herein is accurate.  \n  I affirm that I have reviewed the North Carolina General Statute GS § 90B, the Social Worker Certification and Licensure Act, and Title 21, Chapter 63 of the North Carolina Administrative Code, including the Administrative Rules, Ethical Guidelines, and Disciplinary Procedures; and I hereby agree to fully comply with them. (Please reference the Board’s website at [www.ncswboard.gov](www.ncswboard.gov) for the most current edition)  \n  I affirm that I have not violated any of the North Carolina Social Work Certification and Licensure Board governing rules or statutes, including the Ethical Guidelines.  \n  I affirm that I have not been convicted of a crime (excluding minor traffic violations other than DWI/DUI) since my initial application for associate licensure. (Attach letter of explanation if applicable)  \nFull Name  LCSWA license \\#    \nHome Address   \nStreet/P.O. Box City/State/Zip  \nWork Address   \nStreet/P.O. Box City/State/Zip  \nHome Phone\\# Work Phone\\#   \nSignature  Date  LCSW Supervisor Signature   Date   \nLCSW Supervisor to check appropriate space below:  \n  I recommend continued supervised clinical practice at the LCSWA level.  \n  I recommend this LCSWA for LCSW licensure (applicable only after completing all minimum requirements) .  \nPART II: CONTINUING EDUCATION LOG: A minimum of 40 CE hours (4 Ethics) is required for the Short Form for a full two years. If you renewed your LCSWA less than 2 years ago, please refer to the Board’s Position Statement on Continuing Education for pro-rated CE hours needed. No more than ½ your hours (maximum of 20 hrs) may be through Distance Learning courses.  \nYou may duplicate this form or attach your own if necessary. Please sign and date all attachments.  \nList all training (include date attended) and check the appropriate column where applicable for Ethics or Distance  \nLearning. PLEASE TOTAL YOUR HOURS TO HELP EXPEDITE PROCESSING.  \n\n|  |\n| --- |\n|  |\n\n_____________________________________________________________________________________________________  \n_____________________________________________________________________________________________________  \n_____________________________________________________________________________________________________  \n______","cbCaifs676c2J0gl","https://ap.wps.com/l/cbCaifs676c2J0gl","pdf",198531,"English","# Part I: Affirmation and Signature\n## Supervised clinical experience and supervision requirements\n## Examination and continuing education requirements\n## Applicant affirmation, references, and signature blocks\n# Part II: Continuing Education Log\n## Continuing education hour requirements and tracking table\n# Public Notice Statement","[{\"question\":\"Who is eligible to use this LCSW short-form application?\",\"answer\":\"It is intended only for LCSW Associate licensees who have completed all requirements for LCSW licensure.\"},{\"question\":\"What minimum supervised clinical experience and supervision hours are required?\",\"answer\":\"The applicant must document 3,000 hours of paid supervised clinical experience over a period no less than 2 years and no more than 6 years, and must complete a minimum of 100 hours of clinical supervision.\"},{\"question\":\"What continuing education hours are required, and what ethics requirement applies?\",\"answer\":\"A minimum of 40 CE hours is required for a full two years, including at least 4 hours focused on ethics in social work practice.\"},{\"question\":\"What must be included regarding the public notice statement certification?\",\"answer\":\"The applicant must certify that they read and understand the public notice statement maintained by the N.C. Industrial Commission and disclose whether they have been investigated for employee misclassification within the past twelve months or since the last renewal.\"}]","LCSW Short-Form Application - Three-Part Document - Part I - Affirmation and Signature | PDF",1789824333]