NON-Licensure Certification Request - Medical Quality Assurance

COMPLETE, PRINT AND ATTACH $25 PROCESSING FEE FOR EACH REQUEST (Make check or money order payable to the appropriate licensing board.)
Return form and fee to:	Division of Medical Quality Assurance Licensure Support Services Post Office Box 6320 Tallahassee, FL 32314-6320

NON-LICENSURE CERTIFICATION FORM
Items to be Researched:
Name:
License Number:
Profession:
Certification to be sent to:
Name or State
Mailing address
City/State/Zip Code
Telephone number:	Area Code:	Number:
Special instructions to processor (limit to five lines):
If you wish to have the certification faxed or emailed, include your fax number and/or email address. (Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.)
FAX Number:	Area Code:	Number:
Email Address:

This page was last modified on: 06/18/2013 02:21:07