Ohio Form Rcb 020 – Fill Out and Use This PDF

NBRC CREDENTIAL VERIFICATION FORM

OHIO RESPIRATORY CARE BOARD 77 S. High Street, 16th Floor Columbus, Ohio 43215-6108 614.752.9218 www.state.oh.us/rsp

TO APPLICANT:

The National Board for Respiratory Care, Inc. (NBRC) requires a fee to verify professional credentials. Please complete Section 1 below and submit it, along with the required fee to:

NBRC Executive Office

18000 W. 105th Street

Olathe, KS 66061-7543

FEES (Based on active or inactive NBRC membership):

$5 fee for active members $20 fee for inactive members

SECTION 1:

_____ I am applying for state licensure in (STATE NAME __________________), and I am requesting

the NBRC to verify my credential(s) directly to the (STATE AGENCY

______________________________).

I hold the following NBRC credentials:

PRINT NAME UNDER WHICH YOU WERE CREDENTIALED:

_______________________________________________________________

_______ - _______ - ________

Social Security Number

_______________________________________________________________

LastFirst Middle Initial Former Name

_______________________________________________________________

Street /Apt. #

_______________________________________________________________

CityState Zip Code

_______________________________________________________________

Business PhoneHome Phone

_______________________________________________________________