Licensure List Request

Public Records Request Form

Before you complete this form you must call the board office at 601-352-2918 and determine the number of pages this request will produce. There is a $1.00 per page fee. Enter that number here:

Your Contact Information
*First Name
Initial
*Last Name
Is this information for:	Company or Individual
Employer's Name (If Applicable)
*Address
Address 2
*City
*State
*Zip
*Phone
*Email

Please indicate how you would like to receive the records. Board orders are in paper form only. A disciplinary action list can be sent either by e-mail or paper form.
Email
Paper Copies


Specific records requested: These records will be used for (brief explanation):
There is a minimum $10.00 processing fee per item on all requested documents in addition to the following fees: 8 ½” x 11” $1.00/per page
Part 3101 Chapter 5 of the Regulations contains pertinent information regarding public records request and additional fees.


If you have any questions regarding this form, you may call 601-352-2918.