License/Certification Verification Request
Complete verifications must be mailed directly from the licensing agency to: Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling 4052 Bald Cypress Way Bin C-08 Tallahassee, FL 32399-3258
License/Certification 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 Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling.
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 5048, Revised 8/2020, Rule 64B4-3.001, F.A.C.
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