Ibclc Certification Verification printable pdf download

Ibclc Certification Verification

IBCLC CERTIFICATION VERIFICATION

Name of IBCLC: ________________________________________________________

(please print)

IBCLC ID Number: _____________________________________________________

Expiration Date: ________________________________________________________

I, ____________________________________authorize the release of the information

Name of IBCLC

in the box below to:

________________________________________________

Name

________________________________________________________________

Title

________________________________________________________________

Organization

Verification should be sent via fax to ____________________________ or by email to

Fax Number

_____________________________________________________________________.

Email Address

____________________________________

_________________________

Signature of IBCLC

Date

**The only information IBLCE will releases in regards to the IBCLC named above is in the

box below. Please note that the verification process may take up to two weeks.

Incomplete applications will NOT be processed.

Office Use Only

Year 1

Certified:

Expiration Date:

Date Verified:

Verified By:

***Please fax this completed form to 703-560-7332***

6402 Arlington Blvd. • Suite 350 • Falls Church, VA 22042

703.560.7330 • 703.560.7332 (fax) • •

Ibclc Certification Verification