Form 46158 - Application For Registration As An Environmental Health Specialist Page 3

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VERIFICATION OF STATE REGISTRATION

Applicant instructions: type or print the top section. Send copy to each state where you hold or have or held a registration. Request states to complete and send directly to:

Health Professions Bureau

402 W. Washington St., Room 041

Indianapolis, Indiana 46204

Name (Last, first, middle) (maiden)

Address (Number, street R.R. city state Zip code)

Registration number

Date of issuance

Date of birth

I hereby authorize the State of ___________________________________________________________ to provide the following information to the Indiana Board of

Environmental Health Specialists.

Signature

Date

____________________________________________________________ was registered as an environmental health specialist in ______________________ on,

___________________________ 19 _____.

Registration is current and in good standing and has not been the subject of revocation, suspension, probation, reprimand

or other public or private censure.

Registration has been the subject of disciplinary action, copies of which are attached.

Name

Title

State board

Date