Alc/Drug Counselor--Out-of-state License Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
ALCOHOL AND DRUG COUNSELOR

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 are now or have ever been licensed, certified or registered as an alcohol and drug counselor (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 or Certification
Original License or Certification
Date Issued

MonthDayYear
In (State)
State
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/Cert/Reg Number In the state of State to practice as an alcohol and drug counselor effective Date .
Current Status:
Date license, certification or registration expires:

MonthDayYear
What was the basis for licensure / certification / registration in your state?
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?
Name/Title
Name/Title
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
State/Agency
State/Agency
Date

MonthDayYear
PLEASE COMPLETE AND RETURN DIRECTLY TO:

Department of Public Health
ADC Licensure/Certification
410 Capitol Ave., MS #12APP
P.O. Box 340308
Hartford, CT 06134-0308
(860) 509-7603 • Web site: www.dph.state.ct.us
Should be Empty:

STATE OF CONNECTICUT

ALCOHOL AND DRUG COUNSELOR