Submit Verification to Another Entity

License Verification Recipient Information

Please provide details for the recipient of the license verification documentation including the name of an individual and the Board that are to receive the information, the full address of the Board including state, and country and an email address to whom the license verification document should be sent. If you do not have the name or email of the recipient of the license verification please mark the appropriate box next to the field indicating you do not have that information.

Verification Recipient Name

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Verification Recipient email address

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Board Name

Street Address

City

State/Province

Zip/Postal Code

Country

Reason for Verification

Please provide the reason for verification. Once completed with this form, click Pay(if applicable) and Submit.

Reason for Submitting Service Request

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