(Only used for Supervised (CR) and Apartment Treatment). 1. Fill out the form legibly.Your application must include a recent psychiatric evaluation, a recent psychosocial evaluation and a client consent form. May A. Mendoz authorized Anthony N. Zabala to act on her behalf for all matters relating to her application for a DTI Certificate, including signing documents. The PDF version of these forms are FILLABLE. They can be filled out electronically, then printed. A professional license is the authorization to practice and use a professional title in New York State. Your license is valid for life unless it is revoked. Answer every question in the space provided. • You and the Registered Representative should each retain a copy of the completed form for your records.