Lost Professional License Never Received
This form is for if you have never received the original copy of your license due to mailing issues.
Please fill out and submit this form to have the Board office mail you another copy of your license.
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Full Legal Name *
Which long-term care profession is your  lost license for? *
What is the licensure type for the lost license?
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License Number. If you do not know your license number please look it up here: https://nha.hlb.state.mn.us/#/services/onlineEntitySearch 
Have you ever received  physical version of the license you are requesting from BELTSS *
If this is a secondary license the Board approved it for a specific facility. What is the  MDH issued  HFID number of that facility. *
What is the address you want the replacement mailed to? *
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