REQUEST FOR LICENSE VERIFICATION
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY ? GAVIN NEWSOM, GOVERNOR
SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD 1601 Response Road, Suite260, Sacramento, CA 95815 P (916) 287-7915 | speechandhearing.
REQUEST FOR LICENSE VERIFICATION
AUDIOLOGIST, SPEECH-LANGUAGE PATHOLOGIST (SLP), SLP ASSISTANTS, SLP OR AUDIOLOGY AIDES $25
INSTRUCTIONS: This form must be completed to request verification of your license to another state or entity. If you are requesting more than one License Verification, please submit a separate form for each request. All requests must include the $25.00 processing fee per request, which may be submitted by either check or money order. You may include one check for multiple requests.
NOTE: If you would like to have your verification sent by overnight mail, (e.g. UPS, FedEx,), a prepaid envelope must be included with your request. It will be processed in the date order it is was received but will be sent with the prepaid envelope. Otherwise, the verification will be sent by regular mail and also e-mailed to the agency identified below.
LICENSEE INFORMATION:
NAME:_________________________________________________________________________
(Please provide name the license was issued under if different from current name)
LICENSE TYPE: (Check one) SLP AU
SPA RPE AIDE
LICENSE NUMBER:______________________ LICENSE ISSUE DATE:____________________
EXPIRATION DATE: ______________________________
TELEPHONE (Include area code):_______________________
EMAIL: _________________________________________
AGENCY INFORMATION:
AGENCY NAME (If Applicable):_______________________________________________________ ATTENTION:____________________________________________________________________ MAILING ADDRESS (Street):________________________________________________________ MAILING ADDRESS (City, State, Zip Code):______________________________________________ EMAIL ADDRESS:______________________________________________________________
This certification is provided in good faith. If the fee does not clear the financial institution, this certification is considered invalid and the licensee will be notified.
SIGNATURE: _____________________________________________ DATE: _________________
[LV 200/REV 12/2021]
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