THE AMERICAN BOARD OF PATHOLOGY
VERIFICATION OF CERTIFICATION REQUEST FORM

INSTRUCTIONS:
Please submit the full name and the Last 4 digits of social security number or the Date Of Birth for each verification request.
A fee of $35.00 per physician verified is required with this request.
Requests will be completed in 5-7 business days.
Once this form is completed, please click the "Continue to the Payment page" button at the bottom to complete your payment on the next page.
This form allows you to submit requests for a maximum of five (5) physicians at a time. Please come back to this form multiple times, after each payment, if you need to send us requests for more than five physicians.

List of physician(s) to be verified

1

2

3

4

5

Send Verification Letter(s) to:

Name:

Address:

Payment Details

Total:

$

Continue to the Payment page       

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