Physician/Surgeon: School Verification Form

Public Health: School Verification Form

DPH Data Management and Governance (PLIS)
APPLICANT : Please complete Section 1 of this form and forward it to your medical school

THIS FORM, IN ADDITION TO AN OFFICIAL TRANSCRIPT, NEED ONLY BE SUBMITTED IF THE APPLICANT EARNED A DEGREE OUTSIDE OF THE UNITED STATES OR CANADA
Section 1:
Name of Applicant:
Date of Birth:

MonthDayYear
Year of Graduation:
Section 2: (This section to be completed by the medical school.)
This office has received an application for Connecticut physician licensure from the individual identified above. In order to complete our review of this individual’s credentials for licensure, a verification of educational background is needed. The information below should be completed by the Dean, Registrar or other official authorized to verify educational records at the institution.
Name of Educational Institution:
Address of Educational Institution:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates of Studies: From

MonthDayYear
To:

MonthDayYear
Total number of months of full-time classroom and supervised clinical instruction (record in MONTHS only):
Did this individual satisfactorily complete the full medical curriculum at this institution?
Was this individual granted a degree?
Title of Degree:
Date Awarded:

MonthDayYear
At the time of this student’s attendance, was this medical school fully licensed and approved, by the appropriate regulatory body of the jurisdiction in which it is located, to award the degree of doctor of medicine or its equivalent?
Signature:
Date:

MonthDayYear
Title:
(SEAL)
Please return this form directly to:
Connecticut Department of Public Health
Physician Licensure
410 Capitol Ave, MS #12 APP
P.O. Box 340308
Hartford, CT 06134
Should be Empty:

Public Health: School Verification Form

Section 1:

Section 2: (This section to be completed by the medical school.)