Wyoming Board of Speech Pathology and Audiology 2001 Capitol Avenue, Room 103 Cheyenne WY 82002 307.777.3628 LICENSURE VERIFICATION REQUEST (From Wyoming to another state) 1. Your Information Last Name

First Name

Mailing Address

City

(

Middle Initial

State

Zip Code

)

Phone Number

E-mail Address Questions regarding your request will be emailed to you.

License #

2. State/Agency Receiving Verification If your state requires that we mail this verification directly to you, check this box. List below the mailing and contact information for the state receiving your verification, even if you checked the box above.

State/Agency Name

Contact Name (if applicable)

Mailing Address

City

State

Zip Code

3. Fee Required The Board of Speech Pathology and Audiology charges a $25 fee per license/certificate to verify your license information. This fee shall be a CASHIER’S CHECK OR MONEY ORDER ONLY, made payable to the State of Wyoming for $25. Credit cards, personal checks and business checks are not accepted. Upon receipt of this fee, processing time is generally 2-3 weeks.

4. Release of Information I hereby authorize the Wyoming Board of Speech Pathology and Audiology to release information relating to my license(s) to the agency listed above, including information relating to disciplinary action, suspension, or curtailment of privileges. I further agree to release and hold harmless the Wyoming Board of Speech Pathology and Audiology, its agents, and all staff members from any and all liability for releasing such information.

Signature

Date

Submit this form to the mailing address above. Revised 4/2016

Verify My Wyoming License.pdf

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