Mailing List Purchase Request

Mailing lists are available for a $100.00 fee by following the procedures below. Please fill out this form with your contact information. Then you will be taken to the Mississippi State payment system to make your online payment. Both the form and fee are needed to fulfill the request. You should allow approximately two business days for our office to process your request.
*Format: Mailing list information is available through this office as a comma delimited file (spreadsheet). The mailing list will be emailed to the email address you enter below.
Your Contact Information
*Vendor Name:
*Contact First Name:
*Contact Last Name:
*Address
*City, State Zip	,   Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
*Phone
*Email
*For what purpose are you requesting a mailing list?
The Board is providing the information below pursuant to the Mississippi Public Records Act, Miss Code. Ann. § 25-61-1. The available information is of active licensed psychologists, which includes name, mailing address, business phone number, fax number, email, license number, issue date, and expiration date. The fee for a mailing list is $100.00. After you submit this form you will be taken to the payment screen..