C. Requestor Contact Information:
Name: Telephone #:
Email Address:
B. Certication 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 Verications
P.O. Box 6320 • Tallahassee, FL 32314-6320
Licensure Certication 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 certication, please complete
and forward the Waiver of Condentiality and Authorization to Release Scores Form with your request for
certication. 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 Certication 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