Application for Licensure 07-2016
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.
Page 11 of 12
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- verification of work experience florida department of
- license verification form florida department of health
- florida board of nursing license verification request
- state of florida department of health florida board of
- florida contractor license verification information and
- application for licensure 07 2016
- bureau of education testing florida department of
- florida board of medicine medical doctor
Related searches
- application for financial aid
- federal application for financial aid
- application for federal student loan forgi
- application for federal student loan forgiv
- application for federal student loan forgiveness
- cps application for employment
- application for teacher loan forgiveness
- nycha housing application for rent
- cna reciprocity application for iowa
- application for federal student loans
- application for free money
- application for employment sample