Get Duplicate Certificate Request Form - Mississippi State Department Of ...

Filling out the Duplicate Certificate Request Form is a straightforward process designed for individuals who have completed a Tuberculosis Surveillance & Testing Certification Workshop. This guide will help you navigate the form step-by-step to request a replacement certificate seamlessly.

Follow the steps to complete your Duplicate Certificate Request Form.

1. Click ‘Get Form’ button to access the Duplicate Certificate Request Form and open it in your preferred editor.
2. Begin by providing your name in the designated area. Ensure that you print your name clearly for proper identification.
3. Enter your date of birth in the specified field, as this information is crucial for verifying your identity.
4. Acknowledge the $15 fee for processing your request by checking or signing the relevant statement included in the form.
5. Fill in the course date and location where you completed the Tuberculosis Surveillance and Testing Certification Workshop.
6. If applicable, provide your maiden name to assist in matching your records.
7. Enter your email address and mailing address. These details are important for receiving the confirmation and the certificate.
8. Provide a contact telephone number and fax number if available, as this may be used for any necessary follow-up regarding your request.
9. Indicate your employer's name in the associated field.
10. Confirm that you are requesting the Tuberculosis Surveillance & Testing Certification: Certificate of Completion in the appropriate section.
11. Sign and date the form at the end to validate your request.
12. Once you have completed the form, save your changes and print it for your records.
13. Prepare an acceptable form of payment (company check, certified check, or money order) payable to 'MSDH Tuberculosis Program,' and include this with your form when submitting.
14. Mail the completed form and payment to the specified address provided on the form.

Submit your Duplicate Certificate Request Form online to receive your copy promptly!