Mississippi State Department of Health

Duplicate Certificate Request

1Duplicate Certificate Request
2Review
3Signature
4Disclaimer

Please complete the information below to receive a duplicate or replacement copy of your Tuberculosis Training Certificate.

First Name:

Last Name:

Course Date:

Date of Birth:

Maiden Name:

Email:

Workshop Location:

Employer:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Please take a moment to verify that the information below is correct. Select Continue to remit your payment online. If your address is incorrect, please select Back.

Name:

Email:

Date of Birth:

Course Date:

Workshop Location:

Employer:

Address:

Phone Number:

I hereby acknowledge there is a $15.00 NON REFUNDABLE fee for the reproduction of a Certificate of Completion for the Tuberculosis Surveillance and Testing Course. I have completed, to the best of my knowledge, the information pertaining to which class I completed and where I received my certification. I understand that I must submit an acceptable form of payment to receive a duplicate certificate. Email confirmation will be sent upon receipt of acceptable payment.

In order to make payment and complete your request, you will be redirected to the Mississippi Enterprise Payment System. You will be guided through the payment process and then be returned here to receive your payment confirmation and any additional requirements that may apply. By using this payment system, you attest that you are the account holder or have the written authority to use said account for the purpose of completeing the financial obligations and that sufficient funds are available.

Duplicate Certificate Request

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