Homeopathy: Postgrad Training Verification

  • Public Health: Post-doctoral Homeopathic Training Verification Form

    DPH Data Management and Governance (PLIS)

  • APPLICANT: Enter your full name and birth date on this form and forward it to the Program Administrator for completion. This form must be completed by the program administrator and returned directly to this office.

  • Date of Birth:*
     - -

  • Chief of Staff/Program Director

    Please provide the following verification of post-doctoral training for the above-named Connecticut physician.
  • Dates of training: From
     - -
  • To:
     - -
  • At the time of the applicant's training, was the training program approved by American Institute of Homeopathy?
  • At the time of the applicant’s training, was the training program approved by the Connecticut Homeopathic Medical Examining Board?
  • Did the applicant satisfactorily complete this period of post-doctoral training?
  • Do you have any derogatory information regarding the competency or conduct of this applicant?

  • If Yes, please attach any disclosable documents you may have on file regarding such information.

  • I,         , being duly sworn, do depose and certify that I am the Chief of Staff/Program Director at:

  • Format: (000) 000-0000.

  • Subscribed and sworn to me this  day of (month/ year)      

  • My Commission Expires:
     - -

  • Please complete and return directly to:
    Department of Public Health
    Homeopathic Physician Licensure
    410 Capitol Ave., MS# 12APP
    P.O. Box 340308
    Hartford, CT 06134-0308

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