Degree Earned Outside US Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
SCHOOL VERIFICATION FORM
THIS FORM NEED ONLY BE COMPLETED IF THE APPLICANT EARNED A BACCALAUREATE DEGREE OUTSIDE OF THE UNITED STATES.

Applicant: Complete Section 1 and forward to your education program.

Section 1:
Name of Applicant*

First NameLast Name
Date of Birth*

MonthDayYear
Year of Graduation*
Section 2: (This section to be completed by the school).

This office has received an application for Connecticut athletic trainer 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

Name of Educational Institution

Street Address Line 2

CityState / Province

Postal / Zip Code
Address of Educational Institution
Address of Educational Institution
Dates of Studies: From

MonthDayYear
To

MonthDayYear
YesNo
Title of Degree
Title of Degree
Date Awarded

MonthDayYear
YesNo
Signature
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date

MonthDayYear
Title
Title
Please return this form directly to:

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