Application for Genetic Counselor Licensure

Military Service

Are you active military?
Are you the spouse of an active member of the military?

Biographical Information

Contact Information

You must indicate both a home address and a business address. If you do not have a business address, please indicate your home address in both sections.

Business Address

Please include apartment or suite number with your street address.

Home Address

Please include apartment or suite number with your street address.

Mail Preference

Email Preference: