www.azrra.gov
Douglas A. Ducey
Governor
Aubrey V. Godwin
Director
COSMETIC LASER DUPLICATE CERTIFICATE REQUEST
If you need a duplicate certificate please fill out the following form and submit it with
a payment of $20 by cash or check (made out to the Laser Safety Fund).
*If you are requesting a duplicate certificate at the time of your renewal submit this
form with the renewal form. The fee for a duplicate at time of renewal is only $10
plus the cost of the renewal.
Name:
____________________________________
CLT #:
___________________
Address:
___________________________
Address 2:
__________________________
City: ________________ State: ____ Zip:
_________
Phone Number:
___________________
Email:
__________________________________________
Employer(s) Name:
____________________________________
____________________________________
Work Phone(s):
____________________________
____________________________
My certificate has been lost or stolen so I am requesting a replacement.
I work at 2 facilities so I need 1 duplicate certificate.
I work at _____ facilities, so I need ____
duplicate certificates.
