Request for Certificate of Completion

National Commision on Orthotic & Prosthetic Education

REQUEST FOR CERTIFICATE OF COMPLETION/STATE LICENSURE VERIFICATION FORM

Name of Former
Resident:

Type of Residency:

Current Phone or
Email:

Date of Request:

Effective January 1, 2011, NCOPE will charge a fee of $25.00 for state licensure verification letters and certificates of completion reprints (all residents receive one certificate of completion when residency program is completed) Please do not send cash. Make checks and money orders payable to NCOPE. Mail completed form with payment to NCOPE. Requests take 2 weeks to process. NCOPE will notify you when request is received. All State Licensure Verification Letters will be forwarded directly to state licensure agency and a copy will be mailed to the requester.

Residency Information

Name of Facility:

Residency Director/Supervisor:

Address:

Start Date
End Date

City, State, ZIP:

Your Current Address,
City, State, ZIP:

Request Summary (please check all that apply)	Rate	Quantity	Costs
State Licensure Verification Letter State:	$12.00
Standard Certificate of Completion	$0.00
Replacement/Duplicate Certificate	$5.00
Other (specify)

	Total
For Office Use Only

NCOPE Position Statement on Non-Competes

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