Verification Request Form

Please complete the below fields.

* Indicates required information
Name during Training - Last: * 
Name during Training - Last: 
Alternate Last Name 
Name during Training - First: * 
Programs: * 
(check at least one box, may click more than one) 
Year of Graduation: * 
Program Director Name: 
FOR BOARD CERTIFICATION OR STATE LICENSURE
Please attach Release of Information with hand-written signature of graduate along with additional required documentation you may require.

FOR EMPLOYMENT VERIFICATIONS FOR ORGANIZATIONS OTHER THAN BOARDS/LICENSURE:
Please attach ONLY release of information with hand-written signature of graduate.
VIRGINIA MASON MEDICAL CENTER provides a standard verification form.
DO NOT UPLOAD YOUR ORGANIZATION'S FORMS FOR COMPLETION.
Upload PDF file: * 
(All documents in a single PDF file) 
Email address for return of verification: *