Acupuncturist: Verification of Course of Study Form

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
ACUPUNCTURE LICENSURE

VERIFICATION OF COURSE OF STUDY
APPLICANT: PLEASE COMPLETE THE TOP PORTION OF THIS FORM AND FORWARD TO THE EDUCATIONAL INSTITUTION FOR OFFICIAL VERIFICATION OF COMPLETION OF A COURSE OF STUDY IN ACUPUNCTURE.
Last Name*
Last Name
First Name*
First Name
Middle Name
Middle Name
Maiden Name
Maiden Name
Date of Birth*

MonthDayYear
Social Security Number*
Social Security Number
I hereby authorize the Authorized Entity * to furnish the Connecticut Department of Public Health the information requested below.
Signature *
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date *

MonthDayYear
TO BE COMPLETED BY EDUCATIONAL INSTITUTION ONLY

The applicant listed above is applying for acupuncture licensure in Connecticut. Please provide the following information regarding the course of study that such individual completed at your institution.
Name & Address of Institution
Name and Address of Institution
YesNo
YesNo
How many total hours of training did this individual satisfactorily complete within such course of study?
Total Training Hours
Of these, how many hours were strictly clinical in nature?
Total Clinical Training Hours
Where was such instruction completed?
Clinical Training Facility
Dates of individual's attendance: from

MonthDayYear
to

MonthDayYear
Signature of authorized representative
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date Signed

MonthDayYear
Title
Title
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Thank you for your prompt attention to this matter. Please return this form directly to:

DEPARTMENT OF PUBLIC HEALTH
ACUPUNCTURE LICENSURE
410 CAPITOL AVE., MS# 12APP
P.O. BOX 340308
HARTFORD, CT 06134-0308
(860) 509-7603
Should be Empty:

STATE OF CONNECTICUT

ACUPUNCTURE LICENSURE