Free 07143.FH11 - Indiana

VERIFICATION OF STATE LICENSURE
State Form 7143 (R4 / 2-06)

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PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 232-2960 Fax: (317) 233-4236 www.pla.IN.gov

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Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

INSTRUCTIONS: Type and complete the top section. Make copies to send to each state that you hold or have held a license. Have the state(s) send this directly to our office.

Name (last, first, middle, maiden) Address (number and street or rural route) City Type of license held License number State

Date of birth (month, day, year)

Social Security number *

ZIP code Date of issuance (month, day, year)

I hereby authorize the State of ______________________________ to furnish the Professional Licensing Agency with the information below.
Signature of applicant Date signed (month, day, year)

DO NOT WRITE BELOW THIS LINE

License number Licensed by

Date of issuance (month, day, year) Type of examination

Date of expiration (month, day, year) Date of administration (month, day, year)

Exam

Endorsement

Other Attach subjects, scores, date of examination, and average.

License is current and in good standing

License is or has been invalid

Any derogatory information?

Yes

No

Yes

No

Yes

No

If license has been encumbered in any way, please provide certified copies of all related documents.

FORM COMPLETED BY
Signature Printed name State Board Telephone number Title E-mail address Date (month, day, year)

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Please affix board seal below