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Reset Form APPLICATION FOR LICENSURE AS A MARRIAGE AND FAMILY THERAPIST LMFT State Form 50710 R6 / 8-16 Approved by State Board of Accounts 2016 INSTRUCTIONS BEHAVIORAL HEALTH AND HUMAN SERVICES LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street Room W072 Indianapolis Indiana 46204 Telephone 317 234-2054 E-mail pla8 pla.IN.gov www. Pla.in.gov The fee for this application is 50. 00 payable to the Indiana Professional Licensing Agency in accordance with 839 IAC 1-2-5....

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Application for licensure as is a formal request submitted to obtain a license or certification in a specific field or profession.

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