Form 08-4056 - Application For Audiologist License - 2000 Page 4
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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
VERIFICATION OF AUDIOLOGIST LICENSURE
Part I
Instructions to Applicant: Type or print the information needed to complete Part I of this form. Forward a
verification to each jurisdiction where you previously were or currently are licensed as an audiologist. The
information requested below must be officially verified by the agency or board that issued the license. The blank
form may be photocopied for additional requests. It is the applicant's responsibility to request all necessary
verifications and pay all applicable fees. Upon completion of Part II, the licensing agency will return the form directly
to Alaska.
Name
Last
First
Middle
Maiden/Other
Mailing Address
City
State
ZIP Code
License #
SS#
Birthdate
Signature
Date Signed
PLEASE DO NOT DETACH
Part II
Instructions to Licensing Agency or Board: The above-named individual is applying for licensure as an
audiologist in Alaska. Please provide the information requested below, and return the form directly to the
Division of Occupational Licensing at the address at the top of the page. The verification is not to be returned
to the applicant. In lieu of this form, the State of Alaska will accept a standard computer verification that provides
approximately the same information.
Licensee's Name as Shown on your Records:
License #
SS#
Birthdate
Original Issue Date
Current Expiration Date
Status:
Current
Inactive
Lapsed
Other
Licensed By:
Exam (Date
)
Credentials
Other, please specify:
List derogatory information, if any
(BOARD SEAL)
Signed:
Printed Name:
Return to: Division of Occupational Licensing
Title:
P.O. Box 110806, Juneau, AK 99811-0806
Jurisdiction:
Date:
08-4056b (Rev. 8/00)
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