Written License Verification Request Form - Delaware Division Of Professional Regulation
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1: (302) 744-4500
TELEPHONE
C
B
ANNON
UILDING
: (302) 739-2711
FAX
STATE OF DELAWARE
861 S
L
B
., S
203
ILVER
AKE
LVD
UITE
:
.
.
WEBSITE
DPR
DELAWARE
GOV
D
, D
19904-2467
OVER
ELAWARE
EMAIL
customerservice.dpr@state.de.us
:
WRITTEN LICENSE VERIFICATION REQUEST FORM
1. REQUESTER INFORMATION
Street: _________________________________________
First Name: _________________________________
P.O. Box: _______________
Last Name: _________________________________
City: __________________________
Organization Name: __________________________
State: __________________________ Zip: ____________
Phone: ___________________________
Email – required to receive confirmation when verification is released: ______________________________________
2. LICENSEE INFORMATION
If licensee is a person:
If licensee is a business or organization:
Name: _______________________________________
First Name: ___________________________________
Location: _____________________________________
Last/Family Name: _____________________________
City: __________________________
Social Security Number: _________________________
State: ______________________ Zip: _____________
Profession: ___________________________________
Delaware License Number: ______________________
Delaware License Number: ______________________
3. ADDRESS WHERE WRITTEN VERIFICATION IS TO BE MAILED
MS Board of Dental Examiners The Benjamin Rush Building Spring Grove Hospital Cen
Name: ________________________________________________________________________________________
55 Wade Avenue
ATTEN:Ms. Sandy Sage
Street: _____________________________________________________________ P.O. Box: _________________
Catonsville
MD
21228
City: ________________________________________ State: _________________________ Zip: ______________
4. TYPE OF VERIFICATION (Check one)
Standard Verification (Includes license status, expiration date and disciplinary indicator) - $35.00
•
If you wish to verify a Delaware Physician M.D., Physician D.O., ACGME Training or Physician-Limited
license, do not submit this form unless the verification is for the Veterans Administration. You must submit
your request to VeriDoc.
•
If you wish to verify a Delaware RN or LPN license, do not submit this form unless the verification is for a visa
screen or for the Veterans Administration. Either print out an
online verification
or go to
Accountancy CPA Exam Scores - $45.00
CPA Exam Score verification is available only to persons who hold Delaware Accountancy Permits or Certificates.
All others must order a
Candidate Score Transfer
from the National Association of State Boards of Accountancy
(NASBA).
Architect Exam Scores - $45.00
Cosmetology/Barbering Exam Scores or School Hours - $45.00
Pharmacy Internship Hours - $45.00
Real Estate Licensure History - $45.00
Verification of Supervised Hours - $45.00
Mail your request to the address above. Faxed or emailed requests will not be processed.
VERIFICATION REQUESTS RECEIVED WITHOUT THE CORRECT PAYMENT WILL BE REJECTED.
Revised 6/2016
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