Verification of Licensure and Certification of State Board ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the upper portion of the form. Enter your Last Name, First Name, Middle Name, and any Other Names you have been known by. Ensure accuracy as this information is crucial for identification.
3. Next, input your Date of Birth in the format (mm/dd/yy) and the Last 4 Digits of your Social Security Number. This helps verify your identity.
4. Provide your License Number and Date Issued (mm/dd/yy). This information is essential for the State Board's records.
5. Fill in your Street Address, City, State, and Zip Code to ensure proper communication with the State Board.
6. Sign and date the authorization section at the bottom of the upper portion to allow information release to the Oregon Medical Board.
7. Once completed, send this form directly to each State Board where you have applied for an UNLIMITED License.

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