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Click ‘Get Form’ to open the Telephone (209) 468-6818 application in the editor.
Begin by selecting whether you are applying for an Initial or Renewal EMR certification. This is crucial as it determines the required documentation.
Fill in your personal details, including Last Name, First Name, SSN or TIN, Date of Birth, and any Alias/Maiden Name. Ensure all information is legible and accurate.
Indicate your Race/Ethnicity and Gender by checking the appropriate boxes provided in the form.
Complete your Mailing Address and Residence Address if different. Include City, State, and Zip Code for both addresses.
Provide your Home Phone Number, Cell Phone Number, Email Address, and Driver’s License Number along with the State of Issue.
Read through the certification statement carefully before signing and dating it at the bottom of the form.
If applicable, complete the Affidavit section by answering all questions truthfully and attaching any necessary documents.
Finally, review your application checklist to ensure all required documents are included before submission.

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