Perfusion: Experience Verification

Public Health: Perfusionist-verification Of Perfusion Cases

DPH Data Management and Governance (PLIS)
TO BE COMPLETED BY APPLICANT
Applicant: Please complete the top portion of this form and forward it to the institution(s) where you completed perfusion cases.
First Name:
Middle Name
Last Name
Maiden Name
Date Of Birth:

MonthDayYear
TO BE COMPLETED BY FACILITY ONLY
The above individual is applying for a Connecticut perfusionist license. Please provide the following information:

I certify that the above named applicant was employed as a perfusionist at this facility from Date to Date as a Perfusionist and during that time, this applicant performed AT LEAST FIFTY (50) perfusion cases.
If the applicant did not complete at least 50 perfusion cases, please indicate the number of case completed:
Was this period of employment satisfactorily completed?
If NO, please attach any documents you may have on file regarding such information
Name:
Title:
Signature:
Date:

MonthDayYear
Name of Facility:
Full Address of Facility:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime telephone number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Your prompt attention to this matter is appreciated, as this application cannot be processed until this information is received.

Please return this form directly to:
Department of Public Health
Perfusionist Licensure
410 Capitol Ave., MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1982
Should be Empty:

Public Health: Perfusionist-verification Of Perfusion Cases

TO BE COMPLETED BY APPLICANT

TO BE COMPLETED BY FACILITY ONLY