Form 7143 - Verification Of State Licensure
Download a blank fillable Form 7143 - Verification Of State Licensure in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 7143 - Verification Of State Licensure with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1* PRIVACY NOTICE *
HEALTH PROFESSIONS BUREAU
Indiana Government Center South
This State agency is requesting
402 W. Washington St., Rm 041
disclosure of your Social Security number,
VERIFICATION OF STATE LICENSURE
under I C 4-1-8-1. D iscl os ur e is
Indianapolis, Indiana 46204
State Form 7143 (R2 / 10-91)
mandatory, and this form will not be
Telephone: (317) 232-2960
processed without it.
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
, to furnish the Health Profession Bureau of Indiana with the information below.
Signature
Required pursuant to IC 4-1-8-1
*
DO NOT WRITE BELOW THIS LINE
Licensed by
License number
Date of Issuance (month, day, year)
Exam
Endorsement
Other
Type of Examination
Date of Administration (month, day, year)
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.
FORM COMPLETED BY:
Name
Title
Signature
State Board
Date (month, day, year)
* PRIVACY NOTICE *
* PRIVACY NOTICE *
HEALTH PROFESSIONS BUREAU
Indiana Government Center South
This State agency is requesting
disclosure of your Social Security number,
402 W. Washington St., Rm 041
VERIFICATION OF STATE LICENSURE
under I C 4-1-8-1. D iscl os ur e is
Indianapolis, Indiana 46204
mandatory, and this form will not be
State Form 7143 (R2 / 10-91)
Telephone: (317) 232-2960
processed without it.
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
, to furnish the Health Profession Bureau of Indiana with the information below.
Signature
Required pursuant to IC 4-1-8-1
*
DO NOT WRITE BELOW THIS LINE
Licensed by
Date of Issuance (month, day, year)
License number
Exam
Endorsement
Other
Type of Examination
Date of Administration (month, day, year)
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.
FORM COMPLETED BY:
Name
Title
Signature
State Board
Date (month, day, year)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal