Audiologist--Work Experience Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF OUT-OF-STATE LICENSED OR CERTIFIED WORK EXPERIENCE
PROFESSIONAL EMPLOYMENT AREA: AUDIOLOGY
CANDIDATE’S NAME*

First NameLast Name
ADDRESS*

Street Address

City, State, Zip Code

CityState / Province

Postal / Zip Code
PLACE OF EMPLOYMENT BEING VERIFIED*

Name

Street Address

CityState / Province

Postal / Zip Code
TO BE COMPLETED BY THE EMPLOYMENT SUPERVISOR
SUPERVISOR’S NAME

Last NameFirst NameMiddle Name
PLACE OF EMPLOYMENT

Name

Street Address

CityState / Province

Postal / Zip Code
LICENSE / CERTIFICATE Number
License or Certificate Number
STATE
State
DATE ISSUED

MonthDayYear
YesNo
IF YES, DATE OF CERTIFICATION

MonthDayYear
BUSINESS TELEPHONE
Please enter a valid phone number.Format: (000) 000-0000.
INCLUSIVE DATES OF CANDIDATES EMPLOYMENT: FROM

MonthDayYear
TO

MonthDayYear
HOURS PER WEEK CANDIDATE WORKED
Number of Hours Per Week
WEEKS PER YEAR
Number of Weeks Per Year
PLEASE WRITE YOUR EVALUATION OF THE CANDIDATE CONCERNING THE CANDIDATE’S ABILITY TO FUNCTION COMPETENTLY WITHOUT SUPERVISION AND THE CANDIDATE’S CONFORMANCE WITH ACCEPTED STANDARDS OF PROFESSIONAL PRACTICE.
Enter Evaluation
DATE

MonthDayYear
SIGNATURE
Enter Full Legal Name
I affirm or attest that this is my legal signature.
THANK YOU FOR YOUR ASSISTANCE.

THIS VERIFICATION SHOULD BE SUBMITTED BY THE SUPERVISOR DIRECTLY TO:

DEPARTMENT OF PUBLIC HEALTH
AUDIOLOGIST LICENSURE
410 CAPITOL AVE., MS# 12APP
P.O. BOX 340308
HARTFORD, CT 06134-0308
Should be Empty:

STATE OF CONNECTICUT

VERIFICATION OF OUT-OF-STATE LICENSED OR CERTIFIED WORK EXPERIENCE