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Get Reset Form Application For Licensure As A Clinical Addiction Counselor (lcac) Behavioral Health And

72 Indianapolis, Indiana 46204 Telephone: (317) 234-2064 E-mail: pla5 pla.IN.gov State Form 54089 (R3 / 1-13) Approved by State Board of Accounts, 2013 INSTRUCTIONS: Please return this completed form to Professional Licensing Agency at the above stated address. * Your Social Security number is being requested by this state agency in accordance with IC 25-1-5-11. Disclosure is mandatory and this record cannot be processed without it. FOR OFFICE USE ONLY APPLICATION FEE: DATE FEE PAID (month, d.

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