Request for a License Verification

Request for a License Verification

License Type (circle one): LADC | LPC | LPCC Name of Licensee: ______________________________________________ License Number: _______________________________________________ Your Phone Number: ____________________________________________

I am requesting that a license verification be mailed to each of the following recipients:

Recipient 1

Name:

____________________________________________________

Address:

____________________________________________________

____________________________________________________

Recipient 2

Name:

____________________________________________________

Address:

____________________________________________________

____________________________________________________

Note: If you are requesting a license verification for an individual with multiple license types, the license verification fee is required for each requested license type.

Total Recipients: ______________ X $25.00 each =

Total Amount Enclosed:

$

Please make your check or money order payable to: Minnesota Board of Behavioral Health & Therapy

Signature:

Date:

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