Athletic Trainer--Out-of-state License Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
Athletic Trainer 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 athletic trainer (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 athletic trainer effective Date .
Basis for licensure in your state
Current Status
Expiration Date

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?
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
Daytime Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please complete and return directly to:

Department of Public Health
Athletic Trainer Licensure
410 Capitol Ave MS #12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1982
Should be Empty:

STATE OF CONNECTICUT

Athletic Trainer Licensure