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         License Verification Request

License verification request are available for a $25.00 fee by following the procedures below. Please fill out this form with your contact information. Then you will be taken to the Mississippi State payment system to make your online payment. Both the form and fee are needed to fulfill the request. You should allow approximately two business weeks for our office to process your request.
Verification Requested For:  
License Number:
Full Name:
Your Contact Information  
*First Name
*Last Name
*Company Name

If you have any questions regarding this form,
you may call the office number below.