Generic Fax Cover Page - Delaware

FAX COVER PAGE
CANNON BUILDING
861
SILVER LAKE BLVD., SUITE 203
D
OVER, DELAWARE 19904-2467
STATE OF DELAWARE
DIVISION OF PROFESSIONAL REGULATION
TELEPHONE: (302) 744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerserv[email protected]ate.de.us
To:
From:
Total
Pa
g
es:
Phone:
Fax:
Fax:
Date:
Email:
:
______________________ ____________________ ____________________________ ____________________________ ____________________________ _
PLEASE COMPLETE THIS SECTION!
In Regard to: Name(s): ___________ ____________________ ____________________________ ____________________________ ____________
Applic ation Renewal DE License #: __________ _____________ Complaint #: _______________
Other: ______ _____________ _______________________________________________ DE License #: _______________________
Check professio n(s):
None Genetic Counselors Pharmacy
Accountancy Geologi sts Physical Therapy
Acupunct ure/Detox Specialist s Hearing (Audiology, Aid Dispensers) Physician s/Physician A ssistants
Adult Entertainment Home Inspectors Plumbers
Aestheticians Homeowner Electrical Permits Podiatri sts
Architects HVACR Polysomnographers
Athletic Trainers Land Survey ors Prescription Monitoring Program
Barbering Landscape A rchitects Professi onal Counselors
Chemical De pendency Magistrates (Justice of Peace) Psychol ogists
Chiropractic Manufactured Home Real Estate
Combative Sports Marriage and Family Therapy Real Estate Appraisers/Assessors
Controlled Substance Massage and Body work Respi ratory Care
Cosmetology Medical River Pilot s
Deadly We apon Dealers Nail Technici ans Shops/Salons
Dentistry Nursing Social Workers
Dietitians/Nutritionists Nursing Home Administrators Speech Pathologists
Electricians Occupational Therapy Tamper Resistant Prescriptions
Funeral Services Optometrists Veterinary Medici ne
Gaming Paramedics
Comments:
______________________ ____________________ ____________________________ ____________________________ ____________________________ _
______________ ____________________________ ____________________________ ____________________________ ____________________________ _
______________ ____________________________ ____________________________ ____________________________ ____________________________ _
______________ ____________________________ ____________________________ ____________________________ ____________________________ _
10/2013
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