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
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 .
ActiveInactiveLapsed
Date license, certification or registration expires

MonthDayYear
Yes (If yes, please forward all publicly disclosable information regarding the individual’s status and the basis for same. Please advise this office if you require a consent for release of this information from the applicant).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 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