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License Verification Form - South Dakota Board Of Examiners For Speech-Language Pathology

LICENSE VERIFICATION FORM

SOUTH DAKOTA BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY

810 North Main #298

Spearfish, SD 57783

(605) 642-1600

BEFORE SENDING IN THIS REQUEST PLEASE VERIFY WITH THE STATE BOARD OFFICE THAT YOU ARE

REQUESTING THIS FORM BE SENT TO. MANY STATE BOARDS HAVE THEIR OWN FORMS THEY WANT YOU

TO UTILIZE FOR LICENSE VERIFICATIONS. IF THEY DO HAVE A SPECIFIC FORM THEY WANT YOU TO USE

FOR VERIFICATION PLEASE MAIL IT OR EMAIL IT TO THE BOARD OFFICE.

Print or type name of licensee to be verified: _________________________________________

License number: _______________________________

Licensee Phone Number: _________________________

Send license verification to:

Name: _______________________________________________________________________

Attention: _____________________________________________________________________

Address: ______________________________________________________________________

(Mailing Address/PO Box)

(City)

(State)

(Zip)

Phone Number of Board Office: ___________________________________________________

If your address has changed please fill out the information below so we can update your

records:

Licensee Name: ________________________________________________________________

(Last)

(First)

(M.I.)

(Maiden)

Mailing Address:________________________________________________________________

(Street or P.O. Box)

(City)

(State)

(Zip)

Applicant Printed Name: ________________________________________

Applicant Signature: ____________________________________________

Date: ____________________

License Verification Form - South Dakota Board Of Examiners For Speech-Language Pathology