VERIFICATION OF STATE LICENSURE - in
[Pages:1]VERIFICATION OF STATE LICENSURE
State Form 7143 (R2 / 10-91)
* PRIVACY NOTICE *
This State agency is requesting disclosure of your Social Security number, under IC 4-1-8-1. Disclosure is mandatory, and this form will not be processed without it.
HEALTH PROFESSIONS BUREAU Indiana Government Center South 402 W. Washington St., Rm 041
Indianapolis, Indiana 46204 Telephone: (317) 232-2960
INSTRUCTIONS: Type and complete the top section. Make copies to send to each state that you hold or have held a license. Have the state(s) send this directly to our office.
Name (Last, first, middle, maiden)
Health Profession License Held
Social Security Number *
Address (Number, street, or / rural route)
City
State
ZIP code
License number
Date of Issuance (month, day, year)
Date of Birth (month, day, year)
I hereby authorize the State of Signature
, to furnish the Health Profession Bureau of Indiana with the information below.
* Required pursuant to IC 4-1-8-1
License number
Type of Examination
DO NOT WRITE BELOW THIS LINE Date of Issuance (month, day, year)
Date of Administration (month, day, year)
Licensed by Exam
Endorsement
Other
Please Affix Board Seal
Attach subjects, scores, date of examination and average.
License is current and in good standing License is or has been invalid
Any derogatory information ?
Yes
No
Yes
No
Yes
No
If license has been encumbered in any way, please provide certified copies of all related documents.
Name
FORM COMPLETED BY: Title
Signature
State Board
Date (month, day, year)
VERIFICATION OF STATE LICENSURE
State Form 7143 (R2 / 10-91)
* PPRRIVIVAACCYYNNOOTITCIEC*E *
This State agency is requesting disclosure of your Social Security number, under IC 4-1-8-1. Disclosure is mandatory, and this form will not be processed without it.
HEALTH PROFESSIONS BUREAU Indiana Government Center South 402 W. Washington St., Rm 041
Indianapolis, Indiana 46204 Telephone: (317) 232-2960
INSTRUCTIONS: Type and complete the top section. Make copies to send to each state that you hold or have held a license. Have the state(s) send this directly to our office.
Name (Last, first, middle, maiden)
Health Profession License Held
Social Security Number *
Address (Number, street, or / rural route)
City
State
ZIP code
License number
Date of Issuance (month, day, year)
Date of Birth (month, day, year)
I hereby authorize the State of Signature
, to furnish the Health Profession Bureau of Indiana with the information below.
* Required pursuant to IC 4-1-8-1
License number
Type of Examination
DO NOT WRITE BELOW THIS LINE Date of Issuance (month, day, year)
Date of Administration (month, day, year)
Licensed by Exam
Endorsement
Other
Please Affix Board Seal
Attach subjects, scores, date of examination and average.
License is current and in good standing License is or has been invalid
Any derogatory information ?
Yes
No
Yes
No
Yes
No
If license has been encumbered in any way, please provide certified copies of all related documents.
Name
FORM COMPLETED BY: Title
Signature
State Board
Date (month, day, year)
................
................
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