Healthcare Licensing Application Form

Healthcare Licensing Application Form

Complete this application in full. Omitted or inaccurate information may result in processing delays or denial. All statements are subject to verification. Attach additional pages where necessary and number all attachments to correspond to sections below.

Section 1 — Applicant Information

Date of Birth:    Gender: Male Female Non-binary Other

Section 2 — License Requested

Type of License (select all that apply):

Practitioner — MD/DO    Nurse Practitioner    Physician Assistant    Facility — Clinic/Hospital/Lab    Other (specify):

Section 3 — Professional Credentials

Yes

Section 4 — Employment and Practice History (Last 5 Years)

If gaps in employment exceed 30 days, explain reason(s) and provide dates:

Section 5 — Disciplinary, Criminal and Malpractice History

Have you ever had a license denied, suspended, restricted, revoked, or otherwise disciplined by any licensing authority? Yes No

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony or misdemeanor? Yes No

Have any malpractice claims been filed against you in the last 10 years? Yes No

Section 6 — Authorization, Release, and Certification

By signing this application, the applicant certifies under penalty of perjury that all statements made herein are true, complete, and correct to the best of the applicant's knowledge. The applicant authorizes the licensing authority to obtain and verify information from any relevant source, including but not limited to educational institutions, employers, licensing and disciplinary bodies, law enforcement agencies, and medical records custodians. The applicant releases and holds harmless any person or entity providing information in good faith.

Applicant acknowledges that a false statement, omission, or material misrepresentation may be grounds for denial, restriction, suspension, or revocation of a license and may subject the applicant to criminal or civil penalties under applicable law.

Authorization for release of records and background check valid until:

Applicant consents to fingerprinting, background investigations, and verification of criminal history where required: Yes

Section 7 — Required Attachments (Check all included)

Proof of identity (government-issued)
Official transcripts / education verification
Professional certificates / diplomas
Curriculum vitae
Malpractice history / claims documentation
Application fee payment confirmation

Section 8 — Attestation and Signature

I attest that I have read and understand the requirements for licensure and that I meet the qualifications for the license for which I am applying. I further acknowledge my continuing obligation to report any change in the information contained in this application, including any subsequent arrests, convictions, or disciplinary actions, within the time period required by law or regulation.

If signed by a legal guardian, parent, power of attorney, or other representative, indicate relationship and attach proof of authority:

Warning: Knowingly making a false statement on this application may constitute a criminal offense and may subject the applicant to civil and administrative penalties, including denial or revocation of licensure.

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