Verification Of Supervision

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FORM #5 (OT)
OKLAHOMA STATE BOARD OF
MEDICAL LICENSURE AND SUPERVISION
PO BOX 18256, OKLAHOMA CITY, OK 73154
(405) 962-1400
FAX: (405) 962-1440
VERIFICATION OF SUPERVISION
__________Initial Position
____________Additional Position
__________Change of Position
(first job in the state of Oklahoma)
(do not delete any supervisors already on file)
(delete any supervisors already on file)
(Please print or type)
NAME OF APPLICANT: ______________________________________________________________________________________
License/Application Number: ___________________________________________________________________________________
Mailing Address: _____________________________________________________________________________________________
NAME OF SUPERVISOR: ______________________________________License Number: OT______________________________
NAME OF PRACTICE SETTING (HOSPITAL, CLINIC ETC.) ______________________________________________________
ADDRESS: ________________________________________________________________________________________________
___________________________________________________________________________________________________________
CITY
STATE
ZIP
PRACTICE TELEPHONE NUMBER: (________)_________________________________
THE ABOVE NAMED APPLICANT WILL BEGIN PRACTICE UNDER MY SUPERVISION ON _______/_______/_______.
__________________________________________
_________________________________________
Applicant Signature
Supervisor Signature
NOTE TO SUPERVISOR:
Please notify the Board office when your supervision of this individual ceases.
IN MY ABSENCE, SUPERVISION WILL BE PROVIDED BY:
NAME
LICENSE #
SIGNATURE
______________________________
_____________
____________________________
______________________________
_____________
____________________________
______________________________
_____________
____________________________
______________________________
_____________
____________________________
______________________________
_____________
____________________________
You may mail or fax the completed form

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