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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD
1601 RESPONSE ROAD, SUITE 260, SACRAMENTO, CA 95815
PHONE (916) 287-7915 WWW.SPEECHANDHEARING.CA.GOV
REQUEST FOR LICENSE VERIFICATION
AUDIOLOGIST, SPEECH-LANGUAGE PATHOLOGIST,
SLP ASSISTANTS, AIDES
$10
This form must be completed to request verification of your license to another state or entity. If you are
requesting more than one letter, please submit a separate form for each request. All requests must include
the $10.00 processing fee, which may be submitted by either check or money order. You may include one
check for multiple requests.
If you would like to have your verification sent by overnight mail, (e.g. UPS, FedEx,), a prepaid envelope must
be included with your request. Otherwise, the verification will be sent by regular mail. Please allow 3 weeks for
your request to be processed.
LICENSEE INFORMATION:
NAME: ________________________________________________________________________________
(Please provide name the license was issued under if different from current)
LICENSE TYPE: (Check one) SLP AU SPA RPE AIDE
LICENSE NUMBER: ________________________ LICENSE ISSUE DATE: ________________________
EXPIRATION DATE: ________________________
TELEPHONE NO.: _______________________________________________________________________
(Please include area code)
ADDRESS OF AGENCY:
(NAME OF BUSINESS, IF APPLICABLE)
(ATTENTION)
(STREET)
(CITY, STATE, ZIP CODE)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
SIGNATURE:
_____________________________________________ DATE: _________________
[LV 200/REV 10/16]
