Audiologist--Out-of-state License Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
SPEECH AND LANGUAGE PATHOLOGY / AUDIOLOGY LICENSURE

VERIFICATION OF LICENSURE/CERTIFICATION/REGISTRATION
Applicant - Complete the top portion of this form and forward it to each state where you have been licensed, certified or registered as a speech and language pathologist (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, Certification or Registration 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
DO NOT WRITE BELOW THIS LINE--FOR LICENSING AGENCY USE ONLY
This is to certify that the above named individual was issued license, certification or registration number License/Cert/Reg Number to practice as a speech and language pathologist effective Date .
Current Status:
Date license, certification or registration 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 COMPLETE AND RETURN DIRECTLY TO:
DEPARTMENT OF PUBLIC HEALTH
SPEECH AND LANGUAGE PATHOLOGY/AUDIOLOGY LICENSURE
410 CAPITOL AVE., MS# 12APP
P.O. BOX 340308
HARTFORD, CT 06134-0308
Should be Empty:

STATE OF CONNECTICUT

SPEECH AND LANGUAGE PATHOLOGY /​ ​AUDIOLOGY LICENSURE

SPEECH AND LANGUAGE PATHOLOGY / AUDIOLOGY LICENSURE