C. Requestor Contact Information:
Name: Telephone #:
Email Address:
B. Certication to be Sent to:
Name of person or State Board:
Mailing Address:
City: State: Zip Code:
Telephone #:
Special instructions to processor:
Fax #: Email Address:
Return form and fee to:
Division of Medical Quality Assurance • Licensure Support Services • Attn: License Verications
P.O. Box 6320 • Tallahassee, FL 32314-6320
Licensure Certication Request
PRINT AND ATTACH $25 PROCESSING FEE FOR EACH REQUEST
(Make check or money order payable to the appropriate licensing board.)
If you are requesting that your exam scores be submitted with your request for certication, please complete
and forward the Waiver of Condentiality and Authorization to Release Scores Form with your request for
certication. Please be aware that most states do not require exam scores, please check with the licensing
authority prior to requesting this information. There is no fee associated with Licensure Certication for EMTs,
Paramedics and Radiologic Technicians.
A. Items to be Researched:
Licensee Name: License Number:
License Profession:
(List only numbers)
(List only numbers)
(List only numbers)
Select from this dropdown listing
