License Certification Request

The certificate will state your name, type of license, license number, issue date, date of expiration, disciplinary action or lack thereof, basis of licensure, and the licensure requirements. The certification will be sent directly to the state or Board indicated below.

License Certification $30.00

A $3.00 Convenience Fee will automatically be added to your total.

First Name

Last Name

License Number

Address

City/Town

State/Province

ZIP/Postal Code

Email

You will need to confirm your request using this email

Phone Number

Date of Birth

Last 4 of SSN

List the state or Board email address to which the certification should be emailed. If you do not know the state’s email address, please just enter the state

Acknowledge

I acknowledge that I am applying for a certification request and understand that I will not be refunded if I fill out the incorrect application.

I agree - I understand that by signing electronically, my electronic signature is the legal equivalent of my handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. Under penalty of perjury, I herewith affirm that my electronic signature was signed by myself with my full knowledge and consent.

Signature

Sign above