Form 8521 - Licensure Certification Request - Indiana Professional Licensing Agency Page 2

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Acting on behalf of the ___________________________________________________ , I hereby certifiy that this information is true and correct.
(State of original licensure)
Signature of Secretary
Printed name of Secretary
Name of board
Address of board (number, street)
City and state
Date
A copy of the license law of state of issuance must accompany the application for reciprocal licensure.
BOARD SEAL

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