Verification Letter Request Form

Address *

Requester Information
Name *

First Name Last Name
E-mail Address *
Phone Number *

Area Code Phone Number
Who is requesting the letter? *

I am the candidate/diplomate I am a third party

Self Verification
Does the letter need to include your previous exam results? Note: If you are using the letter for state/licensing purposes, some states require the letter to include your exam results. *

Yes - I authorize the ABR to include all exam results, including pass and fail results No
Do you need a copy of the letter emailed to you? *

Yes No

Third-Party Verification
Does the letter need to include the candidate's / diplomate's previous exam results? Note: If you are using the letter for state licensing/permit purposes, some states require the letter to include exam results. *

Yes - I have attached a signed release from the candidate / diplomate No
Candidate / Diplomate Release

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