Verification of Residency Registration, Completion & Certificate of Completion Request Form

NCOPE charges $30.00 dollars to verify registration / completion of residency for state licensing bodies and $20.00 dollars for residency completion certificate reprints (all residents will receive one complimentary certificate of completion when their residency program is completed) Please do not send cash. NCOPE accepts credit card, check, and money order payments. Credit card payment can be submitted directly to NCOPE using this form. Make checks and money orders payable to NCOPE and include a copy of the completed form. Requests can take up to 2 weeks to process. All state licensure verification letters will be sent certified mail directly to state licensure agency and a copy the letter will be mailed to the requester.

Former Resident Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Did your last name change since registering for residency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Residency Program Information

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{ binding firstError.message }
Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{ binding firstError.message }
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{ binding firstError.message }
Would You Like to Verify the Opposite Discipline Residency as Well? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Was the Opposite Discipline Completed at the Same Facility? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Opposite Discipline Information

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Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Request Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Choose all services that apply

Only select Residency Registration Verification if you are entering into residency in a state whose licensing body requires notification by NCOPE to start the residency.  If you have completed a residency that needs to be disclosed to a state licensing agency, select Completion of Residency Verification.

Identify the Organization Requesting the Verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

State Licensure Verification - Details

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State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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State #2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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State #3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
State #4 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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State #5 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Employer / Patient Care Facility

NCOPE will assess a $30 fee for completing verification documentation to an employer or patient care facility.  Failure to provide all requested information will result in a delay in processing.  

{ binding firstError.message }
Organization Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Contact Person at the Organization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }

Provide copies of any documents that are relevant including releases from the former resident to disclose this information and/or forms that must be filled out by the NCOPE staff to provide to the organization.

{ binding firstError.message }
{ binding firstError.message }

Certificate Reprint - Details

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{ binding firstError.message }

Please enter the name exactly as you would like it printed on the certificate.

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Any verifications for a licensing agency, credentialling body, employer, or patient care facility will not be processed via the "Other" request pathway.  Please select the appropriate reason for this request above in those instances.

{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

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Provide copies of any documents that are relevant including releases from the former resident to disclose this information and/or forms that must be filled out by the NCOPE staff to provide to the organization.

Payment Method {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Please make the check / money order payable to:

NCOPE

Mail payments to:

Verification

c/o NCOPE

330 John Carlyle St 

Suite 200

Alexandria, VA 22314

{~ Payment_Block_Label}

{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}---
{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}

Verification of Residency Registration, Completion & Certificate of Completion Request Form

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

Verification of Residency Registration, Completion & Certificate of Completion Request Form

NCOPE charges $30.00 dollars to verify registration / completion of residency for state licensing bodies and $20.00 dollars for residency completion certificate reprints (all residents will receive one complimentary certificate of completion when their residency program is completed) Please do not send cash. NCOPE accepts credit card, check, and money order payments. Credit card payment can be submitted directly to NCOPE using this form. Make checks and money orders payable to NCOPE and include a copy of the completed form. Requests can take up to 2 weeks to process. All state licensure verification letters will be sent certified mail directly to state licensure agency and a copy the letter will be mailed to the requester.

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

Former Resident Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Did your last name change since registering for residency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Former Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Residency Program Information

Facility Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Residency Director {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Program Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Would You Like to Verify the Opposite Discipline Residency as Well? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Was the Opposite Discipline Completed at the Same Facility? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Opposite Discipline Information

Facility Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Residency Director {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Program Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Request Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Identify the Organization Requesting the Verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

State Licensure Verification - Details

Number of States Where Verification is Required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State #2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State #3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State #4 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State #5 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Employer / Patient Care Facility

NCOPE will assess a $30 fee for completing verification documentation to an employer or patient care facility.  Failure to provide all requested information will result in a delay in processing.  

Organization Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Organization Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Contact Person at the Organization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Contact Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Contact Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Provide a brief explanation why this verification is being requested by the organization listed above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Relevant Documentation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Organization Charge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Certificate Reprint - Details

Number of Certificate Reprints {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Preferred Spelling of Recipients Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Other: Clearly explain the reason for the verification and how the verification should be submitted by the NCOPE staff.   {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Other: Relevant Documentation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Payment Method {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Please make the check / money order payable to:

NCOPE

Mail payments to:

Verification

c/o NCOPE

330 John Carlyle St 

Suite 200

Alexandria, VA 22314