Public Information And Records Request Home Public Information And Records Request What type of request are you submitting? Licensee List Public Records Customer Information First name Last Name Email Email Confirm email Phone Address City State Zip Public Record Public Record Request Options Complaint File Only Licensing File Only Entire Public File Board Meeting(s) - Minutes Board Meeting(s) - Audiotapes/Compact Discs Psychologist or Behavior Analyst Name License Number Minutes date(s) and/or description If you wish to purchase an audiotape or compact disc of a public session of a Board meeting, the cost is $10.00 per audiotape or compact disc. Please write out the dates and description of what is requested. Public Record or License/Certificate Verification Option Psychologist/Behavior Analyst Name Psychologist/Behavioral Analyst License Number Would like this verification to be sent via email or regular mail? Email Regular Mail Verify Email Shipping Address City State Zip Licensee List All Licensees Ever Licensed All Licensees Ever Licensed $0.05/name Licensee List Options All Active Licenses $0.25/name All Active and Inactive Licenses $0.25/name All Active Licenses(residing in Arizona only) $0.25/name All Active and Inactive Licenses(residing in Arizona only) $0.25/name Custom List(By choosing any of these options, the price will automatically increase to $0.35/name) Public Phone Number Licensed Date License Number License Expiration Date Additional Notes Commercial Use Is this request going to be used for commercial use? Yes No Please fill out this Online Request for Public Records, download a copy, and then attach it to this form. Step 1: Fill out the Online Request for Public Records - the form will open in a new window. Step 2: Complete the form and electronicaly sign the form. Step 3: Check your email as you will receive a copy of the form. Down load the .pdf to your computer. Step 4: Attach the copy to this form in the field below. Attachment(s) Upload Please attach any additional information that would help us process your request.Unlimited number of files can be uploaded to this field.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. CAPTCHA What code is in the image? Enter the characters shown in the image. Submit Leave this field blank
