Perfusion: Out-of-state License Verification

Public Health: Perfusionist Licensure

DPH Data Management and Governance (PLIS)
Verification Of Licensure /Certification /Registration
To Be Completed By Applicant
Applicant - Complete the top portion of this form and forward it to each state where you have been licensed as a perfusionist (make copies as necessary).
Last Name:
First Name:
Middle Name:
Maiden Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Original License number (in the state to which the form is being forwarded):
Date Issued :

MonthDayYear
I hereby authorize the Employer / Facility Name* to furnish the Connecticut Department of Public Health the information requested below.
Signature:
Please enter full legal name
Date:

MonthDayYear
To Be Completed By Licensing Agency Only
This is to certify that the above named individual was issued license number license number to practice as a perfusionist effective Date
Basis for licensure in your state:
Current Status:
Date license expires:

MonthDayYear
Important
Has this individual ever been subjected to disciplinary action of any type or is this individual currently the subject of a pending disciplinary action or unresolved complaint?
If yes, please forward all publicly discloseable information regarding the individual’s status and the basis for same.
Signed:
Title:
State:
Date:

MonthDayYear
Day Time Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Please complete and return directly to: Department of Public Health:
Perfusionist Licensure
410 Capitol Avenue MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1982
Should be Empty:

Public Health: Perfusionist Licensure

Verification Of Licensure /Certification /Registration

To Be Completed By Applicant

To Be Completed By Licensing Agency Only