Attachment C "Verification of Certification by Written Examination" - Hawaii

What Is Attachment C?

This is a legal form that was released by the Hawaii Department of Health - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Hawaii Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Attachment C by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

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Download Attachment C "Verification of Certification by Written Examination" - Hawaii

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Attachment C
VIRGINIA PRESSLER, M.D.
DAVID Y. IGE
DIRECTOR OF HEALTH
GOVERNOR OF HAWAII
STATE OF HAWAII
DEPARTMENT OF HEALTH
In reply, please refer to:
STATE LABORATORIES DIVISION
File: SLD/ADMIN
2725 WAIMANO HOME ROAD
PEARL CITY, HAWAII 96782-1496
Verification of Certification by Written Examination
Applicant: Please complete and sign the top part of this form and mail it to the agency that
certified you by written examination. Contact the agency by phone (Attachment B) for the
NOTE: For ASCP certification, please access
correct mailing address for verification.
the ASCP website,
https://www.ascp.org/content/board-of-certification/verify-
credentials
in order to request verification be sent to the state of Hawaii. Do not
use the Attachment C form.
Copies of this form can be used.
Dear Registry Administrator:
I am applying for a clinical laboratory personnel license in the state of Hawaii. Please verify that
I have passed a written examination given by your agency by mailing this letter to:
State of Hawaii Dept. of Health
State Laboratories Division
2725 Waimano Home Rd.
Pearl City, HI 96782
Attn: Licensing
_______________________ ________________________________
________________
Applicant’s Signature
Applicant’s typed or printed name
Date of Birth
_________________________
____________________________
Applicant’s Social Security No.
Date
-------------------------------------------------------------------------------------------------------------------------------
Certification agency, please complete:
Name as it appears on certificate: ___________________________
Profession: _____________________________________________
Certification was issued on _______________ (date) after passing a written examination.
____________________________ ___________________________
________________
Authorized signature
Title
Date
_____________________________________________
(____)________________________
Name of organization
Phone Number
Attachment C 2/1/18
Attachment C
VIRGINIA PRESSLER, M.D.
DAVID Y. IGE
DIRECTOR OF HEALTH
GOVERNOR OF HAWAII
STATE OF HAWAII
DEPARTMENT OF HEALTH
In reply, please refer to:
STATE LABORATORIES DIVISION
File: SLD/ADMIN
2725 WAIMANO HOME ROAD
PEARL CITY, HAWAII 96782-1496
Verification of Certification by Written Examination
Applicant: Please complete and sign the top part of this form and mail it to the agency that
certified you by written examination. Contact the agency by phone (Attachment B) for the
NOTE: For ASCP certification, please access
correct mailing address for verification.
the ASCP website,
https://www.ascp.org/content/board-of-certification/verify-
credentials
in order to request verification be sent to the state of Hawaii. Do not
use the Attachment C form.
Copies of this form can be used.
Dear Registry Administrator:
I am applying for a clinical laboratory personnel license in the state of Hawaii. Please verify that
I have passed a written examination given by your agency by mailing this letter to:
State of Hawaii Dept. of Health
State Laboratories Division
2725 Waimano Home Rd.
Pearl City, HI 96782
Attn: Licensing
_______________________ ________________________________
________________
Applicant’s Signature
Applicant’s typed or printed name
Date of Birth
_________________________
____________________________
Applicant’s Social Security No.
Date
-------------------------------------------------------------------------------------------------------------------------------
Certification agency, please complete:
Name as it appears on certificate: ___________________________
Profession: _____________________________________________
Certification was issued on _______________ (date) after passing a written examination.
____________________________ ___________________________
________________
Authorized signature
Title
Date
_____________________________________________
(____)________________________
Name of organization
Phone Number
Attachment C 2/1/18