Forms

• PDF [486KB] 
  Verification of Education for Licensure in Occupational Therapy PDF [486KB] 
  August 16, 2022
• PDF [112KB] 
  Request to Schedule the Hearing Aid Specialist Licensure Exam PDF [112KB] 
  Updated June 2024
• PDF [249KB] 
  Hearing Aid Specialist Supervision Agreement PDF [249KB] 
  Form 1326, updated July 13, 2022
• PDF [133KB] 
  Respiratory Care Verification of Professional Education PDF [133KB] 
  Form 1310, updated June 2-24
• PDF [162KB] 
  Medical Radiation Technology Verification of Education for Temporary Registration PDF [162KB] 
  Form 1312, Updated June 2024
• PDF [747KB] 
  SLP/A - Supervised Professional Employment Plan (SPEP) PDF [747KB] 
  Form 1325
• PDF [312KB] 
  SLP/A - Supervised Professional Employment Plan (SPEP) Report PDF [312KB] 
  June 1, 2022
• PDF [554KB] 
  SLP/A - Supervised Professional Employment Plan (SPEP) Agreement PDF [554KB] 
  Form 1314
• PDF [180KB] 
  Dietitian Verification of Residence PDF [180KB] 
  Form 1306
• PDF [487KB] 
  Professional Art Therapist Verification of Education PDF [487KB] 
  Form 1305
• PDF [211KB] 
  Change of Location: Tattoo, Permanent Makeup, or Body Piercing Artist PDF [211KB] 
• PDF [171KB] 
  Tattoo and or Body Piercing Inspection Checklist PDF [171KB] 
  July 27, 2022
• PDF [211KB] 
  Tattoo Convention Application for Registration PDF [211KB] 
  Form 1327, June 2024
• PDF [491KB] 
  Supervision Agreement for Provisional Registration for Tattoo and/or Body Piercers PDF [491KB] 
  Form 1324, July 5, 2022
• PDF [9KB] 
  Tattoo/Body Piercing Artist - Consent Form PDF [9KB] 
• PDF [413KB] 
  Supervision Agreement for Limited Permit Applicants PDF [413KB] 
  August 16, 2022
• PDF [488KB] 
  Verification of Credential in Another State PDF [488KB] 
  Form 1304
• PDF [305KB] 
  Employment History PDF [305KB] 
  Form 1303e

Mississippi State Department of Health • 570 East Woodrow Wilson Dr • Jackson, MS 39216 • 866‑HLTHY4U • Contact and information