STATUS LETTER REQUEST

 

EmployerXG username is acceptable if unable to provide employer or license #

 
 
 
 

(First Name, Last Name)

 
 

Please Note: A Status Letter will be generated with the Work Periods and Areas selected below. If you require a Status Letter per Work Period and corresponding Area, please submit multiple form requests.

 

(Select all that applies)

 

(Select all that applies)

 
Drop your files here
 

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