State Form 7143 - Verification Of State Licensure
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1PROFESSIONAL LICENSING AGENCY
VERIFICATION OF STATE LICENSURE
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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.
month, day, year
last, first, middle, maiden
number and street or rural route
month, day, year
month, day, year
DO NOT WRITE BELOW THIS LINE
(month, day, year)
(month, day, year)
(month, day, year)
Attach subjects, scores, date of examination, and average.
If license has been encumbered in any way, please provide certified copies of all related documents.
FORM COMPLETED BY
month, day, year
Please affix board seal below
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Parent category: Legal