Board of Medicine - Verification of NCCAOM Certification Form
Rev. 3/2008 LAC NCCAOM
Verification of NCCAOM Certification
Please complete the following, enclose a $35.00 check payable to the NCCAOM and forward to:
NATIONAL CERTIFICATION COMMISSION FOR ACUPUNCTURE & ORIENTAL MEDICINE
76 South Laura Street, Suite 1290
Jacksonville, FL 32202
I am applying for a license to practice as an acupuncturist in the Commonwealth of Virginia. The Board of Medicine requires that the NCCAOM submit verification of the following. Please complete the form for SCORE VERIFICATION OF NCCAOM CERTIFICATION and send to the above address. Thank you.
_______________________________________ _____________________________________
Applicant’s Name Applicant’s Signature/Date
_______________________________________
Applicant’s Certificate Number
The Score Verification of NCCAOM Certification shall include:
1. Comprehensive Written Examination test date and score
2. Clean Needle Technique Portion test date and score
3. Practical Examination of Point Location Skills test date and score
4. When the Clean Needle Technique Course was passed
5. Certificate Number
6. Certificate expiration
7. Examination Language
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Department of Health Professions
Commonwealth of Virginia
Board of Medicine
9960 Mayland Drive, #300
Henrico, Virginia 23233-1463 (804) 367-4570
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