Fillable OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION APPLICANT: Complete this (California)

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OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION APPLICANT: Complete this (California)

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The OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION APPLICANT: Complete this (California) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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37A-526 (Revised 01/2020)
STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY Gavin Newsom, Governor
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830 TTY: (800) 326-2297
www.bbs.ca.gov
LICENSED CLINICAL SOCIAL WORKER
OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION
APPLICANT: Complete this section authorizing release of information by another state board or
licensing agency. Mail this form and any necessary fees to that state board/licensing agency.
Verification For: Applicant Applicant’s Supervisor
Name of California Applicant:
Last
First
Middle
Date of Birth
Name of Individual to be Verified:
Last
First
Middle
License Number
I hereby authorize the release of my information to the California Board of Behavioral Sciences
Signature of individual to be verified: _________________________________ Date:________
STATE BOARD/LICENSING AGENCY: Please return this form to the above address.
1. Full name as shown in your records: ___________________________________________________
2. License or Registration Title: _________________________________________________________
3. License or Registration Status: _______________________________________________________
Issue Date: __________ Expiration Date: ___________
4. Any disciplinary action? Yes No If YES, attach an explanation.
State Board/Licensing Agency
Stamp Here
Signature of Person Completing Form Date
Printed Name and Title
State Board or Licensing Agency Name
State Phone Number
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OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION APPLICANT: Complete this (California)

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Completed 25 January 2021

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