Speech & Language Pathologist: Out-of-state License Verification

Public Health: Speech And Language Pathology / Audiology Licensure

DPH Data Management and Governance (PLIS)
Verification Of Licensure /Certification /Registration
Applicant- Complete the top portion of this form and forward it to each state where you have been licensed, certified or registered as a speech and language pathologist (make copies as necessary).
Last Name:
First Name:
Middle Name:
Maiden Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Original License, Certification or Registration number (in the state to which the form is being forwarded):
Date Issued:

MonthDayYear
I hereby authorize the Licensing Agency * to furnish the Connecticut Department of Public Health the information requested below.
Signature:
Please enter full legal name
Date:

MonthDayYear
DO NOT WRITE BELOW THIS LINE--FOR LICENSING AGENCY USE ONLY
This is to certify that the above named individual was issued license, certification or registration number:
To practice as a speech and language pathologist effective:
Current Status:
Date license, certification or registration expires:

MonthDayYear
Has this individual ever been subjected to disciplinary action of any type or is this individual currently the subject of a pending disciplinary action or unresolved complaint?
If yes, please forward all publicly disclosable information regarding the individual’s status and the basis for same. Please advise this office if you require a consent for release of this information from the applicant.
SEAL
Signed:
Title:
State:
Date:

MonthDayYear
Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
PLEASE COMPLETE AND RETURN 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 Licensure /Certification /Registration

DO NOT WRITE BELOW THIS LINE--FOR LICENSING AGENCY USE ONLY