Puerto Rico License Verification Order Form 

 
Which Puerto Rico License Verification Service do you Require: Mailed Verification from PR Board - $179 - Emailed Verification from PR Database - $59-
Puerto Rico Medical License Number - Required:
Puerto Rico Medical Registry Number - Required:
Full Legal Name
Mailing Address:
Phone Number:
Email:
Date of Birth:
Place of Birth:
Social Security Number:
Name of Institution Receiving Verification:
Destination Mailing Address:
Name of Person Requesting the Verification:
Contact Phone Number:
Contact Email:
Do you required a PR Examination Verification?  No    Yes - ***If you check "YES" you will be charged an Additional $179.00
Credit Card Number:
Credit Card Expiration Date:
Credit Card 3-4 digit Pin # (on Back of the Card - VISA, MC, or Discover - on Front for AMEX)
Name on the Credit Card:
Billing Address of the Credit Card:

Hit Submit to Complete your Order