Acupuncturist--Out-of-state License Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
ACUPUNCTURE LICENSURE

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, certified or registered as an acupuncturist (make copies as necessary).
Last Name
Last Name
First Name
First Name
Middle Name
Middle Name
Maiden 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 Authorized Entity * to furnish the Connecticut Department of Public Health the information requested below.
Signature
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
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 an acupuncturist effective Date .
Basis for licensure in your state:
Current Status:
Date license expires:

MonthDayYear
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?
SEAL
Signed
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
Title
Title
State
State
Date

MonthDayYear
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
PLEASE RETURN DIRECTLY TO:

Department of Public Health
Acupuncture Licensure
410 Capitol Ave., MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1929
Should be Empty:

STATE OF CONNECTICUT

ACUPUNCTURE LICENSURE