Form 08-601a - Verification Of Naturopath Licensure And Examination printable pdf download

Form 08-601a - Verification Of Naturopath Licensure And Examination

NAT

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

Naturopath Section

P.O. Box 110806, Juneau, Alaska 99811-0806

(907) 465-2695

E-mail: license@dced.state.ak.us

VERIFICATION OF NATUROPATH LICENSURE AND EXAMINATION

Part I

Instructions to Applicant: Type or print the information needed to complete Part I of this form. Forward a

verification to each jurisdiction where you previously were or currently are licensed as a naturopath. The

information requested below must be officially verified by the agency or board that issued the license; your

application cannot be approved for licensure until this information is received. The blank form may be photocopied

for additional requests. It is the applicant's responsibility to request all necessary verifications and pay all applicable

fees. Upon completion of Part II (and Part III, if applicable), the licensing agency will return the form directly to

Alaska.

Name

Last

First

Middle

Maiden/Other

Mailing Address

City

State

ZIP Code

License #

SS#

Birthdate

Signature

Date Signed

PLEASE DO NOT DETACH

Part II

Instructions to Licensing Agency or Board: The above-named individual is applying for licensure as a

naturopath in Alaska. Please provide the information requested in Parts II and III, and return the form directly

to the Division of Occupational Licensing at the address at the top of the page. The verification is not to be

returned to the applicant. In lieu of this form, the State of Alaska will accept a standard computer verification that

provides approximately the same information.

Licensee's Name as Shown on your Records:

License #

SS#

Birthdate

Original Issue Date

Current Expiration Date

Status:

Current

Inactive

Lapsed

Other

Licensed By:

Exam (Date

), see reverse

Credentials

Other, please specify:

List derogatory information, if any

CONTINUED ON REVERSE

08-601a (Rev. 1/00)

(3)

Form 08-601a - Verification Of Naturopath Licensure And Examination

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