Florida Board of Psychology - Licensure/Certification Form
Complete verifications must be mailed directly from the licensing agency to:
Board of Psychology 4052 Bald Cypress Way Bin C-05 Tallahassee, FL 32399-3255
Board of Psychology License Verification Request
Part I: To be completed by applicant (Florida requires verification of all your current and previously held licenses.)
Name: ____________________________________________________________________________________ Address: __________________________________________________________________________________ Name original license was issued under: _________________________________________________________ License Number: _____________________________________ State: _________________________________ I hereby authorize release of any information regarding my licensure status to the Florida Board of Psychology. Applicant Signature: _________________________________________________ Date: __________________
MM/DD/YYYY
Part II: To be completed by state licensing agency
All verifications must be in English and include the following criteria:
* Typed on an official state form or letterhead * Include an official board seal * Signature and title of state board official
The following information must be included in all verifications:
* Licensee name
* License number
* State or jurisdiction of licensure
* Licensure status
* Is license in good standing?
* Date of issuance and expiration
* Licensure method (examination, grandfathering, reciprocity/endorsement) If exam, provide exam
name, exam level, exam date, and score achieved.
* Has this license ever been encumbered (denied, revoked, suspended, surrendered, limited, placed
on probation)?
* If this license has ever been encumbered, please provide certified copies of documentation
regarding the action with the completed license verification.
DH-MQA 1187, Revised 7/2020, Rule 64B19-11.012, F.A.C.
Page 15 of 18
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