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
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 .
EndorsementExamination
ActiveInactiveLapsed
Date license expires:

MonthDayYear
Yes (If yes, please forward all publicly disclosable information regarding the individual’s status and the basis for same).No
SEAL
Signed
Enter Full Legal Name
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