03/2018 Page 1 of 2
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | www.azdo.gov
LICENSE VERIFICATION REQUEST FORM
Use this form to request that a verification of licensure and disciplinary history be sent to another board or organization.
FEE: Please mail your request and a check payable to the Arizona Board of Osteopathic Examiners in the amount of $10.00 per verification to the
address listed above. Payment may also be made by credit card by mailing this form to the address provided above. The information released with
this request is public. Therefore, no signature is required.
Name
of
Licensee
to
be
verified
:
_____________________________________________
Lic.
No
.
__________________
Type of License to be verified: ____ D.O. Physician ____ D.O. PGT Permit ____ D.O. Locum Tenens
Requestor’s name, address and day phone number (If different than licensee):
Name:
______________________________________________
Phone:
_______________________
Add
ress:
________________________________________________________________________________
Address:
________________________________________________________________________________
City, State, Zip:
________________________________________________________________________________
Email:
________________________________________________________________________________
Provide below the name of each organization, facility, or regulatory board to which a verification is to be sent. All state licensing
board addresses are on file, so it is not necessary to provide these.
1. Name
of
Receiving
Board/Organization:
___________________________________________________________________
Address, if other than another state licensing board:
Address:
Address:
City,
State,
Zip:
2. Name
of
Receiving
Board/Organization:
___________________________________________________________________
Address, if other than another state licensing board:
Address:
Address:
City,
State,
Zip:
3. Name
of
Receiving
Board/Organization:
___________________________________________________________________
Address, if other than another state licensing board:
Address:
Address:
City,
State,
Zip:
Verifications are mailed via United States Postal Service. If you wish to have verification sent via some other delivery
s
erv
i
ce
,
you
must provide a pre-completed waybill including the requestor’s account number for payment for each verific
ation
with this request.
Verifications may take up to two (2) weeks to be
p
r
o
ce
ss
e
d
.
