Substance Abuse Counselor: Out-of-state License Verification

Public Health: Alcohol And Drug Counselor Verification Of Licensure/Certification/Registration

DPH Data Management and Governance (PLIS)
TO BE COMPLETED BY APPLICANT
Applicant - Complete the top portion of this form and forward it to each state where you are now or have ever been licensed, certified or registered as an alcohol and drug counselor (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 or Certification
Date Issued:

MonthDayYear
In (State)
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
TO BE COMPLETED BY LICENSING AGENCY ONLY
This is to certify that the above named individual was issued license/certification/ registration number License number in the state of state to practice as an alcohol and drug counselor effective Date
Current Status:
Date license, certification or registration expires:

MonthDayYear
What was the basis for licensure/certification/registration in your state?
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.
Name:
Title:
Telephone:
Please enter a valid phone number.Format: (000) 000-0000.
Signature:
State/Agency:
Date:

MonthDayYear
Please complete and return directly to:
Department of Public Health
ADC Licensure/Certification
410 Capitol Ave., MS #12APP
P.O. Box 340308
Hartford, CT 06134-0308
(860) 509-7603 • Web site: www.dph.state.ct.us
Should be Empty:

Public Health: Alcohol And Drug Counselor Verification Of Licensure/Certification/Registration

TO BE COMPLETED BY APPLICANT

TO BE COMPLETED BY LICENSING AGENCY ONLY