Application for Licensure - Personal Information

Application Type

Please select the application type

Applicant Information

Please provide the information below.

Have you ever been known under any other name(s)?
Will documents be received in another name?
Create a Password

Please create a password that you will use going forward to log in to all online forms including: updating your personal/employment information, printing your license, future renewal forms, etc.

Passwords must be at least 8 (eight) characters in length and include at least 1 (one) uppercase letter, lowercase letter, number and special character.
Special characters allowed are: ! $ % & * ( ) - [ ] { } , / : ?

Page Updated: 1/18/2023 9:09:58 AM