Form 08-4056 - Application For Audiologist License - 2000 Page 3
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5AUD
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Audiology/Hearing Aid Dealer/Speech-Language Pathology Section
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
AUDIOLOGY PROFESSIONAL REFERENCE / WORK EXPERIENCE
I certify that the applicant, ______________________________________________________, has engaged in
(Name of Applicant)
the practice of audiology from
to ______________________; and I am or was professionally
associated with the applicant during the dates stated.
PERSONAL STATEMENT:
Signature
Date
Printed Name
Title
Address
City/State/ZIP Code
SUBSCRIBED AND SWORN TO before me on
_____________________________ (date).
Notary Public, State of
(NOTARY SEAL)
My commission expires:
08-4056a (Rev. 8/00)
(3)
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