Verification Request Form

For trainees whose last day at Virginia Mason was greater than two years ago.

Please complete the below fields.

FOR BOARD CERTIFICATION OR STATE LICENSURE
Please attach Release of Information with hand-written signature of graduate along with additional required documentation you may require.

FOR EMPLOYMENT VERIFICATIONS FOR ORGANIZATIONS OTHER THAN BOARDS/LICENSURE
Please attach ONLY release of information with hand-written signature of graduate.
VIRGINIA MASON MEDICAL CENTER provides a standard verification form.

DO NOT UPLOAD YOUR ORGANIZATION'S FORMS FOR COMPLETION.

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Payment Information

Amount due: $75. The confirmation page will include a link to enter your credit card information.



* Required