Please Return Your Request and Full Payment to:

The Division of Professional Licensure Computer Services Department 1000 Washington Street, Suite 710 Boston, Massachusetts 02118-6100 617-727-1794
http://www.mass.gov/dpl

Application to Request Current Licensee Databases

Date of Request Name of Requestor Email Address Telephone Number

Please specify below where you would like the CD-ROM to be sent (NO SHIPPING TO PO BOXES)
Attention Address1 (NO PO BOXES) Address2 (NO PO BOXES) City, State, Zip Code Check here to pick up CD. If picking up CD, arrangements must be made before doing so. Please call the number above to make such arrangements. There is no guarantee the CD will be ready when you arrive.

These databases cannot be emailed They may be too large and/or some Antivirus programs will not accept databases that are emailed. The CDs are shipped within ten days via two-day UPS. The fee for each checked box is $30.00; OR, $30.00 if ALL PROFESSIONS is checked. All checks should be made payable to: THE COMMONWEALTH OF MASSACHUSETTS
Check All Boxes that Apply (If Choosing ALL OF THE ABOVE PROFESSIONS Only Choose That Box) Alarm System Installers Allied Health Professionals Allied Mental Health and Human Services Professionals Architects Barbers Barber Shops and Barber Schools Chiropractors Cosmetologists Dietitians/Nutritionists Dispensing Opticians Drinking Water Facility Operators Electricians Electrologists Embalmers and Funeral Directors Funeral Establishments Gasfitters Hair Salons and Shops Health Officers Hearing Instrument Specialists Home Inspectors Landscape Architects Massage Therapists Optometrists Plumbers Podiatrists Professional Engineers and Land Surveyors Public Accountants Psychologists Real Estate Appraisers Real Estate Sales and Brokers Sanitarians Sheet Metal Workers Social Workers Speech-Language Pathologists & Audiologists Television and Radio Repair Technicians Veterinarians

RESET FORM
Number of Boxes Checked FEE CALCULATION
EXAMPLE CALCULATION

ALL PROFESSIONS
Times Fee Per Checked Box Times $30.00
Times $30.00 per box =

Equals Total Amount Due

0
3 boxes checked

$0.00
Equals $90.00 due

Request Number

FOR DIVISION OF PROFESSIONAL LICENSURE USE ONLY Date Received Date Sent Processed By

Check Number

Effective 04/20/2010

KEEP THIS PAGE FOR YOUR RECORDS

Architects (AR), Certified Health Officers (HO), Dietitians and Nutritionists (NU), Dispensing Opticians (DO), Funeral Establishments (FE), Landscape Architects (LA), Podiatrists (PD), Sanitarians (SA) Alarm System Installers (FA) Allied Health Professionals (AH)

THE FOLLOWING DATABASES CONTAIN ONE PROFESSION ONLY

DATABASES (BOARD CODE)

Allied Mental Health and Human Services Professionals (MH) Barber Shops and Barber Schools (BS) Barbers (BR) Chiropractors (CH) Cosmetologists (HD) Drinking Water Facility Operators (DW)

Systems Contractor, Systems Installer (These are Alarm and Fire Alarm Professionals under the Electricians Board) Athletic Trainer, Occupational Therapist, Occupational Therapy Assistant, Physical Therapist, Physical Therapist Assistant, Physical Therapy Facility Educational Psychologist, Marriage & Family Therapist, Mental Health Counselor, Rehabilitation Therapist Barber Shop, Barber School Apprentice Barber, Master Barber, Barber Instructor Chiropractor, Chiropractic Facility Aesthetician Instructor, Registered Aesthetician I, Registered Aesthetician II, Registered Cosmetologist, Registered Demonstrator, Registered Instructor, Registered Manicurist, Registered Operator Dual Certification 1, Dual Certification 2, Dual Certification 3, Dual Certification 4, Dual Certification C1, Dual Certification C2, Dual Certification C3, Dual Certification C4, Grade 1D Operator In Training, Grade 1T Operator In Training, Grade 2D Operator In Training, Grade 2T Operator In Training, Grade 3D Operator In Training, Grade 3T Operator In Training, Grade 4D Operator In Training, Grade 4T Operator In Training, Grade VSS Operator In Training, Licensed Grade 1D Full Operator, Licensed Grade 1T Full Operator, Licensed Grade 2D Full Operator, Licensed Grade 2T Full Operator, Licensed Grade 3D Full Operator, Licensed Grade 3T Full Operator, Licensed Grade 4D Full Operator, Licensed Grade 4T Full Operator, Licensed Grade VND 1D Operator, Licensed Grade VND 1T Operator, Licensed Grade VND 2D Operator, Licensed Grade VND 2T Operator, Licensed Grade VND 3T Operator, Licensed Grade VND 4T Operator, Licensed Grade VSS Full Operator Journeyman Electrician, Master Electrician Registered Electrologist, Registered Electrologist/Lecturer, Registered Electrology Instructor, Registered Electrology School Certified Funeral Director, Licensed Funeral Director, Registered Embalmer, Registered Embalmer & Licensed Funeral Director, Registered Embalmer Apprentice, Registered Unlicensed Funeral Director Apprentice Gasfitter, Gasfitting Corporation, Gasfitting Partnership, Journeyman Gasfitter, Journeyman Gasfitter/Inspector, Limited Undiluted Liquefied Petroleum Installer, Master Gasfitter, Master Gasfitter/Inspector, Undiluted Liquefied Petroleum Gas Installer Hearing Instrument (Hearing Aid) Specialist Advanced Training Institute, Aesthetician School, Aesthetic Shop, Booth Renter, Booth Shop, Cosmetology Salon, Cosmetology School, Manicuring Shop, Registered Manicuring School Associate Home Inspector, Home Inspector Solo Massage Establishment, Multiple Massage Establishment, Massage Therapist (Massage Instructor and , Massage Schools are not yet licensed) Optometrist, DPA Certified Optometrist, TPA Certified Optometrist Apprentice Plumber, Journeyman Plumber, Journeyman Plumber/Inspector, Master Plumber, Master Plumber/Inspector, Plumbing Corporation, Plumbing Partnership Acoustical Engineer, Civil Engineer, Electrical Engineer, Industrial Engineer, Mechanical Engineer, Plumbing Engineer, Aeronautical/Aerospace Engineer, Aeronautical Engineer, Agricultural Engineer, Architectural Marine Engineer, Architectural Engineer, Aerospace Engineer, Astronautical Engineer, Ceramic Engineer, Chemical Engineer, Construction Engineer, Corrosion Engineer, Control Systems Engineer, Engineer In Training, Electronic Engineer, Environmental Engineer, Engineering Physics Engineers, Fire Protection Engineer, Geological Engineer, Geodetic Engineer, Geotechnical Engineer, Highway Engineer, Heating & Ventilation Engineer, Instrumentation Engineer, Surveyor In Training, Land Surveyor, Marine Engineer, Metallurgical Engineer, Mining and Mineral Engineer, Manufacturing Engineer, Materials Engineer, Naval Architecture, Nuclear Engineer, Petroleum Engineer, Plastics Engineer, Quality Engineer, Railroad Engineer, Sanitary Engineer, Safety Engineer, Structural Engineer, Systems Engineer, Traffic Engineer, Transportation Engineer, Textile Engineer Certified Public Accountant, CPA Corporation, CPA Partnership, Business Corporation, CPA Limited Liability Company, CPA Limited Liability Partnership Licensed Psychologist, Licensed Psychologist NP (Non-Provider), Licensed Psychologist HSP Registered Technician, Registered Master Technician Real Estate Appraisal Program/CE, Real Estate Appraisal School/Primary, Certified General, Certified Residential, State Licensed, Trainee Broker, Corporation, Salesperson, Attorney Broker, Limited Liability Company, Limited Liability Partnership, Partnership/Corporation, General Partnership, Limited Partnership, Reciprocal Broker, Real Estate Program, Reciprocal Salesperson, Sheet Metal Worker (Apprentice, Journeyperson, Master), Sheet Metal Work Business, Sheet Metal Work School Licensed Independent Clinical Social Worker, Licensed Certified Social Worker, Licensed Social Worker, Licensed Social Worker Associate Audiologist, Audiologist Assistant, Speech Pathologist, Speech Pathologist Assistant Veterinarian, Limited Practitioner

MULTIPLE PROFESSIONS ARE WITHIN EACH DATABASE

Electricians (EL) Electrologists (ET) Embalmers and Funeral Directors (EM) Gasfitters (GF) Hearing Instrument Specialists (HE) Hair Salons, Schools and Shops (HS) Home Inspectors (HI) Massage Therapists (MT) Optometrists (OP) Plumbers (PL) Professional Engineers and Professional Land Surveyors (EN)

Public Accountants (CA) Psychologists (PY) Radio and Television Technicians (TV) Real Estate Appraisers (RA) Real Estate Brokers & Salespersons (RE) Sheet Metal Workers (SM) Social Workers (SW) Speech-Language Pathologists and Audiologists (SP) Veterinarians (VT)

For more information and frequently asked questions regarding the licensee databases, please visit our website at http://www.mass.gov/dpl and click the Request Licensee Databases link.