Den Hygiene

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments