Disciplinary Information Request Form

This is not a verification tool. If you need to verify a license (go to Verify a License). You will need a case # to use this screen. If there is no case # on the verification form then there is no disciplinary history.  

 
Please provide us with the following information so that we can provide you with the appropriate information. 
Important Notes:
  • You must press the tab key to move from field to field in the form below. If you press the enter key, you will accidentally submit the form.
  • Please enter requestor information in the form or were unable to contact you with the disciplinary information request.

Licensee/Case Information

 
   
Licensee Name (First/Last):   OR Business Name:
Business Address: 
 City: 
 State: 
 Zip: 
License #: 
 Case #: 

Requestor Information

 
Name (First/Last):  
Address: 
 City: 
 State: 
 Zip: 
Phone: 
 Fax: 
Email:
Additional Notes: