Speech & Language Pathologist: Work Experience Verification

Public Health: Speech And Language Pathology / Audiology Licensure Verification Of Out-of-state Licensed Or Certified Work Experience

DPH Data Management and Governance (PLIS)
Professional Employment Area: Speech And Language Pathology
Candidate’s Name: *
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of employment being verified:*
Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To Be Completed By The Employment Supervisor:
Supervisor’s Name :
Last Name
First Name:
Middle Name
Place Of Employment:
Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
License/Certificate No:
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:
Weeks per year:
Please write your evaluation of the candidate on the reverse side of this form concerning the candidate’s ability to function competently without supervision and the candidate’s conformance with accepted standards of professional practice.
Date:

MonthDayYear
Signature:
Thank you for your assistance

This verification should be submitted by the supervisor 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:

Public Health: Speech And Language Pathology / Audiology Licensure Verification Of Out-of-state Licensed Or Certified Work Experience

Professional Employment Area: Speech And Language Pathology

To Be Completed By The Employment Supervisor: