This form is used to request verification of your license, certificate, or registration from the
Louisiana State Board of Social Work Examiners. Please complete the information below and
send to the attention of Regina DeWitt via fax at (225) 756-3472 or email at
Requestor’s Name ___________________________________
License Number ___________________________________
Address ___________________________________
Contact Number ___________________________________
Fax Number ___________________________________
Email Address ___________________________________
Provide mailing instructions here:
Fee is $5.00 per verification. Payment is required prior to your request being processed. Payments
can be made via credit card or money order. You will be notified if your request cannot be
processed within 3 business days.
Name on Card: _______________________________________________________
Card Type: Visa MasterCard Discover
Card Number:
Expiration Date: 3-digit Security Code (on back):
For Office Use Only: