Request Verification

Requesting Institution Information

Name of Person Requesting Information*
First Last
Institution Name*
Email*
Phone*
Fax
Address*
Street Address Address Line 2 City State ZIP Code
Authorization to Release Information*
Please upload a signed copy of the trainee's Release Statement ONLY.
Additional Forms
Please upload any forms that need to be filled out.
Trainee Information
Please provide the following information regarding the trainee in which you are requesting verification.
Name*
First Last
Is the trainee's current name the same as the name used at the time of CCHHS training?*
- Yes
- No
Name at the Time of CCHHS Training*
Please include the name of the trainee at the time that he/she was in the CCHHS training program.
First Last
Date of Birth*
MM
DD
YYYY
Program Name*
Department*
Start Date*
MM
DD
YYYY
End Date*
MM
DD
YYYY
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