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Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center 3000 Estate Golden Rock, Suite 9 St. Croix, VI 00820-4311 Administrative Complex “The Battery” St. John, VI 00830 Property & Procurement Building 8201 Subbase, Suite 1 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 US VIRGIN ISLANDS BOARD OF SOCIAL WORKERS Instructions for Social Worker Licensure Application New applicants and reciprocity applicants New Applicant Information CISW Applicants 1. An official, certified transcript is required for the master's degree of social work degree and the highest relevant. Please review the educational requirements on page 6 of this application. The transcripts must be in a sealed school envelope and submitted directly to the Board. 2. Applicants must be currently licensed in US Virgin Islands at the CSW level (or equivalent from another jurisdiction). Applicants must provide a copy of their license. 3. Applicants must submit a total of three references (two professional and one supervisory). All references must be able to evaluate the applicant’s social work experience. The waiver of liability must be completed for each reference. The reference form is attached (pages 11-12). Make additional copies as needed. The reference forms are not required to be submitted in a sealed envelope. a. Two professional individuals licensed at the CISW level. At least one at the CISW level or equivalent in another jurisdiction, psychiatry, clinical psychology or psychiatric nursing with a specialty in clinical mental health shall complete section A of a reference form. References must provide a copy of their professional license. b. A clinical supervisor licensed at the CISW level (or equivalent in another jurisdiction) shall complete sections A and B of a reference form and must document: i. For MSW graduates with a degree conferred date after August 31, 2011, a minimum of 3,000 hours clinical social work services experience obtained over a period of not less than two years after the issuance of a CSW, or ii. For MSW graduates with a degree conferred date prior to August 31, 2011, a minimum of 3,000 hours of clinical social work services experience obtained over a period of not less than two years after the MSW degree conferred date. iii. Documented supervision must be a minimum of 100 hours of individual face-to-face clinical supervision, at a rate of 1 hour for every 35 hours worked (with a maximum of 1 hour per week). If the experience is earned at a rate less than 35 hours per week, the experience and supervision hours must be computed on a pro-rata basis. Supervised work experience and hours must correspond to the dates listed on the reference form, or an explanation must be attached. iv. Supervisors must be licensed in the jurisdiction where the supervision takes place; out of state supervisors may not supervise work experience taking place in the VI All work experience must be complete as of the application date. If there are multiple supervisors, submit a separate form for each supervisor (ensuring that the documented dates do not overlap). Supervisors must provide a copy of their professional license. US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 CSW Applicants 1. An official, certified transcript is required for the master's degree of social work degree and the highest relevant. Please review the educational requirements on page 6 of this application. The transcripts must be in a sealed school envelope and submitted directly to the Board. 2. Applicants must submit a total of three references (two professional and one supervisory). At least one of the professional and/or supervisory reference forms must be completed by an individual licensed at the CISW or CSW level (or equivalent). All references must be able to evaluate the applicant’s social work experience. The waiver of liability must be completed for each reference. The reference form is attached (pages 11-12). Make additional copies as needed. The reference forms are not required to be submitted in a sealed envelope. a. Two professional individuals familiar with the applicant’s professional experience in the field of social work shall complete section A of a reference form. References must provide a copy of their professional license. b. The most recent second year field placement supervisor shall complete sections A & B of a reference form. LSW Applicants 1. An official, certified transcript is required at the bachelor’s degree of social work degree. Please review the educational requirements on page 6 of this application. The transcripts must be in a sealed school envelope and submitted directly to the Board. 2. Applicants must submit a total of three references (two professional and one supervisory). All references must be able to evaluate the applicant’s social work experience. The waiver of liability must be completed for each reference. The reference form is attached (pages 11-12). Make additional copies as needed. a. Two professional individuals familiar with the applicant’s professional experience in the field of social work shall complete section A of a reference form. References must provide a copy of their professional license. SWA Applicants 1. An official, certified transcript is required at the bachelor’s degree of social work degree. Please review the educational requirements on page 6 of this application. The transcripts must be in a sealed school envelope and submitted directly to the Board. 2. Applicants must submit a total of three references (two professional and one supervisory). All references must be able to evaluate the applicant’s social work experience. The waiver of liability must be completed for each reference. The reference form is attached (pages 11-12). Make additional copies as needed. b. Two professional individuals familiar with the applicant’s professional experience in the field of social work shall complete section A of a reference form. References must provide a copy of their professional license. New Applicant Summary Checklist New licensure applicants must provide the following: 1. Application, signed and notarized • Signature date must correspond to the date of notarization 2. Payment by certified check or money order (payable to Government of the VI), or credit card information 3. Passport size Photo 4. Official transcript of the highest relevant degree 5. A total of three reference forms completed per instructions • NOTE: CISW, CSW, LSW AND LSWA APPLICANTS- At least one reference form must be completed by an individual currently licensed at the CISW or CSW level (or equivalent). 6. Signed and notarized criminal history acknowledgment form (attached) US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Reciprocity Applicant Information 1. Applicants must possess a current, valid license substantially equivalent to the appropriate US Virgin Islands license in education and experience requirements. A certified licensure verification form for all licenses, current and expired, must be submitted in the original, sealed envelope from the issuing jurisdiction. The form on page 13 of this packet may be used, or the issuing jurisdiction may use its own form. 2. Applicants must have passed the ASWB examination required for the appropriate level of licensure in US Virgin Islands. Refer to page 6 of this application to review the examination requirements. An official ASWB- certified passing score report is required. 3. An official, certified transcript is required. Please review the educational requirements on pages 1-2 of this application for the applicable license level. The transcript must be in a sealed school envelope. 4. Three professional references shall complete section A of a reference form: a. All references must be able to evaluate the applicant’s social work experience. b. CISW, CSW, LSW and SWA applicants: at least one reference must be licensed at the CISW or CSW level, or equivalent. CISW applicants: at least one reference must be licensed at the CISW level, or equivalent. c. The waiver of liability must be completed for each reference. d. The reference form is attached (pages 11-12). Make additional copies as needed. Reciprocity Applicants Summary Checklist Reciprocity applicants must provide the following: 1. Application, signed and notarized • Signature date must correspond to the date of notarization 2. Payment by certified check or money order, payable to “Government of the Virgin Islands,”; or credit card information 3. Passport size photo 4. Official transcript 5. Two reference forms completed by professional individuals, and one reference form completed by an appropriately licensed social worker, as instructed above. 6. Certified verification from all prior licensing jurisdictions. The form included on page 13 of this packet may be used, or the issuing jurisdiction may use its own form 7. An official Certified Score Report of passed ASWB examination from ASWB (888-579-3926) 8. Signed and notarized criminal history acknowledgment form (attached). US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Requirements for Social Work Licensure in US Virgin Islands This is a summary; applicants must review the US Virgin Islands regulations for detailed requirements. Education Examination Professional References Supervision Documented Experience CISW MSW, DSW or PhD in Clinical Two professional One Hold a current LCSW (or Social Work from a CSWE references from supervisory equivalent); two years (3,000 accredited school of social appropriately reference from hours) post-CSW work licensed CISW documented clinical individuals (see experience with 50 face-to- instructions p. 2) face supervision hours per year (100 hours total) under a CISW CSW MSW, DSW or PhD in Masters Three professional One 2 nd year None Required Social Work from a CSWE references * field placement accredited school of social supervisory work reference * LSW Bachelors degree in Social Work from a CSWE accredited school of social work Bachelors Three professional references * One supervisory reference * None required Bachelors degree in Social Work Bachelors Three professional references * One supervisory reference * None required SWA Bachelor’s degree Bachelors Three professional references * N/A None required * At least one of the professional and/or supervisory references must be licensed as a CISW or CSW US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center 3000 Estate Golden Rock, Suite 9 St. Croix, VI 00820-4311 Administrative Complex “The Battery” St. John, VI 00830 Property & Procurement Building 8201 Subbase, Suite 1 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 License Level applying for  Certified Independent Social Worker (CISW)  Certified Social Worker (CSW)  Licensed Social Worker (LSW)  Social Work Associate (SWA) Application Type:  New Applicant  Reciprocity Applicant Special Accommodations Required ?  Yes  No Identification & Contact Information Last Name: First: Middle: NOTE: For examination purposes, your name must match your name as it appears on one current, valid non-expired government issued photo-bearing ID. If you have had a legal name change, please attach pertinent documents (court order, marriage certificate, etc.) attesting to this fact. Maiden/Another Name: Gender:  Female  Male Birth Date: Place of Birth: NOTE: Your social security number is required on page 10 of this application. NOTE: The mailing address below will be a matter of public record. It will appear on your license and will be used for all board correspondence. The mailing address and the business address listed on page 11 may be the same. Mailing Address: PHOTOGRAPH – attach recent 2” x 2” photograph here. Email address: (print clearly) Valor Act Status:  Active Duty  Military Spouse  Veteran  None Business phone: ( ) - Home phone: ( ) - Cellular phone: ( ) - US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Current Employment: Business name: Current position: Date started: Business Address: Education Information: • Certified transcript is required for the highest relevant degree up to an MSW • Transcript must be sent directly to the Board from the school. NO EXCEPTIONS 1) Degree/graduation date: Major: College name and address: 2) Degree/graduation date: Major: College name and address: 3) Degree/graduation date Major: College name and address: ASWB Examinations passed (if any): An official ASWB-certified passing score report is required and must be submitted directly to the Board from ASWB. 1) Exam level Date 2) Exam level Date US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Licensure Information: • List ALL Social Work licenses/certifications, current and expired, from any jurisdiction. • Certified verification form is required from each jurisdiction, except US Virgin Islands. 1) License Designation: State/Province: License number: Date Issued/Expiration date: Status:   Current Expired   Revoked/suspended Under investigation  Other: Basis for License:   Examination Endorsement   Reciprocity Grandparenting  Other: 2) License Designation: State/Province: License number: Date Issued/Expiration date: Status:   Current Expired   Revoked/suspended Under investigation  Other: Basis for License:   Examination Endorsement   Reciprocity Grandparenting  Other: 3) License Designation: State/Province: License number: Date Issued/Expiration date: Status:   Current Expired   Revoked/suspended Under investigation  Other: Basis for License:   Examination Endorsement   Reciprocity Grandparenting  Other: US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Supervisor/Reference Contact Information: • A reference form is required from everyone listed 1) Name (supervisor or reference): Address: City: State/Province: Zip/Postal code: Daytime Phone: ( ) Email: 2) Name (supervisor or reference): Address: City: State/Province: Zip/Postal code: Daytime Phone: ( ) Email: 3) Name (supervisor or reference): Address: City: State/Province: Zip/Postal code: Daytime Phone: ( ) Email: Applicant Attestations: 1. Has a licensing/certification board in any U.S. or foreign jurisdiction taken any disciplinary action against you?  Yes  No 2. Are you the subject of pending disciplinary actions by a licensing/certification board in any U.S. or foreign jurisdiction?  Yes  No 3. Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification board in any U.S. or foreign jurisdiction?  Yes  No 4. Have you ever applied for and been denied a professional license in any U.S. or foreign jurisdiction?  Yes  No 5. Have you ever admitted to or been convicted of a felony or misdemeanor in any U.S. or foreign jurisdiction, other than a traffic violation with an assessed fine of less than $200?  Yes  No 6. CISW APPLICANTS ONLY: You must have submitted a thoroughly completed fully participating or non-billing provider application and signed provider contract to VI Board.  I have complied US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 NOTE: please state the details of any 1 thru 5 “yes” answer on a separate sheet and attach the explanation to this application. DLCA through VIPD will access data about convictions and pending criminal cases. Those records—and other Federal and professional records—will be checked as part of your licensing process. No records are automatic disqualifiers; you will be given an opportunity to discuss any issues with the Board. By signing this form, you are providing your consent for the US Virgin Islands Board of Social Work Licensure and, where relevant, their supervising state agencies and the US Virgin Islands Department of Licensing and Consumer Affairs, and where relevant, its provider enrollment vendor, to obtain, read, copy, and share with each other information regarding your VI Board application and enrollment status and US Virgin Islands licensure status. I certify under the pains and penalties of perjury that the information in this application has been reviewed and signed by me, and is true, accurate and complete, to the best of my knowledge. I understand that the failure to provide accurate information may be grounds for the US Virgin Islands Board of Social Work Licensure to deny me the right to sit as a candidate or to suspend or revoke a license issued to me in accordance with US Virgin Islands’ Law. I further attest that, to the best of my knowledge and belief, I have filed all state tax returns and paid all state taxes required by law. I further certify under the pains and penalties of perjury that, if I am applying for licensure as a CISW, I have submitted a completed application to be a fully participating or nonbilling provider to VI Board. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. *Applicant’s signature: **Date: Notary name (printed): Date: SEAL Notary signature: Commission Expires: * Must be signed in the presence of a notary public ** Signature date must correspond with notarization date; the application must be received within 90 days of the date notarized US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Applicant’s Name: NOTE: This page will not be retained with your application. U.S. Social Security Number Social Security Number (mandatory): NOTE: Pursuant to G.L. c. 62C, s. 47A, the Social Work Board is required to obtain your social security number and forward it to the Department of Revenue to ascertain whether you are in compliance with the tax laws of the US Virgin Islands. Application Payment Application Fees: (due with this application) Indicate application type and fee: (All fees are non-refundable and subject to change.) Applicant is providing all documents (circle Application Type (check below) fee below)  New application Fee (all licenses) $50.00  Certified Indep SW $195.00  Certified Soc. Wrk $130.00  Licensed Soc. Wrk $91.00  Social Wrk Assoc $91.00 Payment Method: □ Certified check or money order- payable to Government of the Virgin Islands OR □ Visa □ MasterCard Credit card number: Exp. Date: MM YYYY CID code (last 3 digits from signature panel on back of card) Card Holder’s Zip Code: Card Holder’s Name (please print): Card Holder’s Signature: US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center 3000 Estate Golden Rock, Suite 9 St. Croix, VI 00820-4311 Administrative Complex “The Battery” St. John, VI 00830 Property & Procurement Building 8201 Subbase, Suite 1 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 This section must be completed by the licensure applicant Applicant’s name: Maiden name or another name: Address: City: State/Province: Zip/Postal Code: Date of graduation (highest degree): Degree conferred: List the highest professional license held: License: License Number/Jurisdiction License applied for (check one):  CISW  CSW  LSW  SWA WAIVER OF LIABILITY- must be completed by the licensure applicant I, , hereby authorize Applicant’s name Reference’s name (hereinafter “the reference”) to provide the Board of Social Worker Licensure with all information of any kind that the reference may, in his or her absolute discretion, deem relevant to my qualifications as an applicant. I hereby release and discharge the professional reference from all claims arising out of the provision of such information. Applicant’s signature: Date: INFORMATION AND INSTRUCTIONS FOR REFERENCES General information for references completing this form: 1. The Board assumes that you, in recommending this applicant, will be willing to interpret or to substantiate to the Board your recommendation, should the Board desire to contact you. The Board will keep all information confidential to the maximum extent permitted by law. 2. Complete this refer en ce for m only if the applicant h as signed the above waiver of liability. 3. Professional References - complete section A and the s ignature block . 4. Supervision R eferences - comp let e sections A and B a nd the s ignature bl o ck . N OTE: experience/supervision hours must correspond to employment dates, please explain if they do not 5. Return pages 1 1 and 1 2 of this r eference form to the applicant in the envelope provided. US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center 3000 Estate Golden Rock, Suite 9 St. Croix, VI 00820-4311 Administrative Complex “The Battery” St. John, VI 00830 Property & Procurement Building 8201 Subbase, Suite 1 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 Applicant’s name: A) ALL REFERENCES- Please complete section A: References must provide a copy of their professional license. Reference’s name: Title: License Type: • Reference’s license number & Jurisdiction: Relationship to applicant: • Dates the reference has known the applicant: from to MM/YY MM/YY • Extent of knowledge of applicant’s professional and ethical behavior:  Thorough  Moderate  Limited • Based on my experience, to the best of my knowledge, the applicant is an individual of good moral character:  Yes  No (If no, please explain on a separate sheet) • Quality and extent of endorsement:  Without reservation  With reservation  No recommendation (If with reservation or no recommendation, please explain on a separate sheet) Reference’s signature: Date: Address: Phone: City: State/Province: Zip/Postal Code: B) SUPERVISION REFERENCES ONLY- Please complete sections A and B: • Supervisor’s degree College/University Major Date of degree □ I certify that I supervised the above applicant in the field of social work at thefollowing organization: from * to * organization MM/DD/YY MM/DD/YY □ The applicant worked hours per week for weeks for a total of * work hours □ I supervised hours per week for a total of * hours of face-to-face supervision • Applicant’s title: Note: * supervision/experience hours must correspond to dates listed • Applicant’s duties/responsibilities: • Areas of applicant’s specialties: US Virgin Islands, Board of Social Workers Social Worker Licensure Application Revised 08/2022 Licensure Verification (Use this form ONLY if you currently hold or ever held a license in a jurisdiction other than US Virgin Islands) Board instructions: return this verification form to the applicant in a sealed envelope Licensee’s name: License Number: The Social Work licensing board verifies the following: Date license issued: Expiration date: 1. This certifies that the above-named individual was issued a license or registration to practice as a: License title: License designation:  Social Worker  Masters Social Worker  Other, please explain:  Independent Social Worker  Clinical Social Worker 2. License or registration was issued based upon:  Examination  Endorsement Exam passed: State/Province: Date exam taken:  Reciprocity  Grandparenting  Other, please explain: 3. The board verified that this individual holds a social work degree:  Yes  No The license was based on this degree:  BSW Social Work  Other (please Doctorate specify below) Degree: Subject: 4. A program accredited by CSWE or CASSW issued the degree:  Yes  No 5. This license required documented post-masters-degree supervised experience:  Yes  No If yes, how much experience was required? years hours Qualifications of the individual who provided supervision: 6. The license or registration is currently:  Active  Expired  Lapsed  Inactive  Other, please explain: 7. This individual has been subject to disciplinary action that is public information:  Yes  No 8. There is pending disciplinary action against this individual that is public information:  Yes  No 9. There are unresolved complaints regarding this individual that are public information:  Yes  No 10. If questions 7, 8, or 9 are answered “yes”, an explanation follows. Other information that the board can share about the licensee that might affect another board’s licensing decision: Board Signature/Date: (Board Seal) Title: Social Work Licensing Board/Jurisdiction: Email Address/Phone Number:  MSW Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Golden Rock Shopping Center 3000 Estate Golden Rock, Suite 9 St. Croix, VI 00820-4311 Administrative Complex “The Battery” St. John, VI 00830 Property & Procurement Building 8201 Subbase, Suite 1 St. Thomas, VI 00802-5826 Telephone: 340.713.3522 Telephone: 340.693.8036 Telephone: 340.714.3522 Facsimile: 340.718.6982 Facsimile: 340.776.6989 Facsimile: 340.776.8303 VI SOCIAL WORK SUPERVISION CALCULATION WORKSHEET Applicant Name: _________________________________ Applicant License #:_______________________ Supervisor’s Name Start Date of Supervision (MM/YYYY) End Date of Supervision (MM/YYYY) GENERAL SUPERVISION Hours Completed FACE TO FACE SUPERVISION Hours Completed Supervisor’s License # Supervisor’s Signature Total Number of Total Number of General Supervision Hours: _______ Immediate / Face to Face Supervision Hours: ____________ NOTE: If the applicant’s experience was obtained in the Virgin Islands, then verify that the applicant and his/her supervisor held a valid VI. license during that period. If the applicant and/or supervisor were not licensed during the period that the applicant’s VI. experience was obtained, then the application packet must be forwarded to the Board for review. Securing the Virgin Islands through Professional Service 5131 Estate Welcome, Christiansted, St. Croix, U.S. Virgin Islands 00820 (340) 773-3110 Fax (340) 773-3113 e-mail: rfrancis@sherawassociates.com July 20.2021 Department of Licensing and Consumer Affair Process for requesting a background check from Secure VI. Send the following documents via E-mail to (rfrancis@secure.vi) 1. Filled Authorization form 2. DLC Application (copy) 3. Submit payment VIA PayPal to www.PayPal.me/secureVI 4. Results will be submitted to DLC as they become available Securing the Virgin Islands through Professional Service 5131 Estate Welcome, Christiansted, St. Croix, U.S. Virgin Islands 00820 (340) 773-3110 Fax (340) 773-3113 e-mail: swagmer@secure.vi AUTHORIZATION AND RELEASE FOR A BACKGROUND INVESTIGATION I, the undersigned, do hereby authorize DLCA, by and through its independent contractor, Dennis R. Sheraw and Associates, Inc. DBA Secure VI, to conduct a Background Investigative History Search on me. I understand that this search can include Federal, State, County and/or Territorial, Criminal and/or Civil Court Records, Credit Bureau, Educational Institutions degrees and transcripts and any other public information sources and agencies. A verification of my Social Security Account Number, Date of Birth, present and past addresses may be required. I further authorize any person, public information source, court, court agency, and/or law enforcement agency who may have information relevant to this Investigative History Search to disclose same to DLCA by and through DRSI including, but not limited to any court, public agency, and any and all law enforcement agencies, regardless of whether such person, business entity, or governmental agency compiled the information itself or received it from other sources. I hereby release DLCA, Secure VI, and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands of whatever kind, to me, my heirs or others making such claim or demand on my behalf for procuring, providing, brokering and/or assisting with the compilation or preparation of the Investigative History Search hereby authorized. PLEASE PRINT ALL INFORMATION PRINTED NAME________________________________________________________________________ FIRST MIDDLE & MAIDEN LAST Alias SOCIAL SECURITY NUMBER_________ -_______ -__________ DATE OF BIRTH_________/_________/__________ M D YEAR Place of Birth CURRENT PHYSCIAL ADDRESS_____________________________________________________________________ Places lived in the past 7 years (Country, State, Territory) (See back of page) Securing the Virgin Islands through Professional Service 5131 Estate Welcome, Christiansted, St. Croix, U.S. Virgin Islands 00820 (340) 773-3110 Fax (340) 773-3113 e-mail: swagmer@secure.vi Ensure that there are no gaps in the dates. Use additional space below in necessary Complete Address – Physical and Mailing Example (35 Estate Welcome, PO Box 11111, Christiansted, VI 00820) From (Date) To (Date) SIGNATURE___________________________________________DATE__________________