Fillable LICENSE VERIFICATION REQUEST FORM (State of Nevada, Department of Information Technology)

Fill Online, Printable, Fillable, Blank LICENSE VERIFICATION REQUEST FORM (State of Nevada, Department of Information Technology) Form

Use Fill to complete blank online STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LICENSE VERIFICATION REQUEST FORM (State of Nevada, Department of Information Technology)

On average this form takes 7 minutes to complete

The LICENSE VERIFICATION REQUEST FORM (State of Nevada, Department of Information Technology) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Nevada, Department of Information Technology

BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Nevada State Board of Medical Examiners
9600 Gateway Drive, Reno, NV 89521
Phone: In Reno/Sparks/Carson City: (775) 688-2559
(If calling from any other area of Nevada, call the Board's in-state, toll-free number: (888 890-8210))
Fax: (775) 688-2321
LICENSE VERIFICATION REQUEST FORM
Please complete and submit this form to request a letter of verification (sometimes called a letter of
good standing) be sent to another regulatory board or other organization. Payment must be submitted
with the completed form. You may pay by cashier’s check or money order, payable to “NEVADA
STATE BOARD OF MEDICAL EXAMINERS,” or by credit card. If paying by credit card, please
complete the Credit Card Authorization Form on the last page of this form. A 2.5% payment-
processing fee will be assessed for payment by credit card.
The fee for each Letter of Verification requested is $25.00.
Licensee Name:
Nevada License No. (if known):
Requester's Name and address (if different than licensee):
Name:
Address:
Contact telephone number and e-mail for requester (in case there are questions pertaining
to your request):
Phone:
E-mail:
Type of license(s) to be verified:
Name and address of the board(s)/organization(s) to which the Letter(s) of Verification is/are
to be sent:
NOTE: If delivery of the Letter(s) of Verification by FedEx, UPS, DSL or a similar company is
requested, an envelope and pre-completed waybill, including requester’s account number for
payment, must be provided with this request form.
CREDIT CARD AUTHORIZATION FORM
If mailing or faxing this page separately from an application or order form, please mail to:
Nevada State Board of Medical Examiners
9600 Gateway Drive
Reno, NV 89521
or fax to: 775-688-2321
Please type or print legibly.
Method of Payment: MasterCard / Visa / American Express / Discover
Name on Credit Card: _______________________________________________________________
Business Name (if applicable): ________________________________________________________
Credit Card Billing Address:
__________________________________
__________________________________
__________________________________
Phone Number: ___________________________
Name of Applicant (if applying for licensure): ____________________________________________
Credit Card Number: ________________________________________________________________
Expiration Date: _____ / _____ Credit Card Verification Code (CVC): _____
(MM) (YYYY) (Three or four digit code found on the front or back of the card)
For security of your financial information, please do not email this form to the Board; emailed forms will
not be accepted.
I authorize the Nevada State Board of Medical Examiners to charge the above credit card for a
One-time payment in the amount of $______________.
Printed Name: ______________________________________________
Authorized Signature: _________________________________________________Date:__________
Email Address for receipt: ______________________________________________
Disclosure: By continuing, you will be charged a non-refundable card payment-processing fee of 2.5% for debit and credit
cards by our payment processor. If you do not wish to pay the fee, you can select another payment option.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LICENSE VERIFICATION REQUEST FORM (State of Nevada, Department of Information Technology)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document