Dhec 4024 form printable-2026

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Click ‘Get Form’ to open the dhec 4024 form in the editor.
Begin by selecting the reason for your application in Line 1. Choose from options a, b, c, or d based on whether you are applying for an initial license or renewal.
In Line 2.a, enter your full name. For Line 2.b, provide your street address where you will conduct midwifery services.
If your mailing address differs from your service address, fill it in Line 2.c. Include both home and business phone numbers in Lines 2.d.
Complete Line 2.e with your date of birth and indicate your sex. In Line 2.f, add your email address if available.
Proceed to check all applicable boxes in Line 3 and provide any additional information requested.
Attach necessary documentation as specified in Lines 4 through 8 to support your application.
Finally, ensure that you sign the verification section at the end of the form before submitting it.

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