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Click ‘Get Form’ to open it in the editor.
Begin by entering your Full Name in the designated field, ensuring you include your First, Middle, and Last Name. If applicable, prepare to upload documentation for any name changes.
Provide your Email address in the next field to ensure communication regarding your application.
Enter two Contact Phone Numbers for follow-up inquiries. Make sure both numbers are accurate and up-to-date.
Fill in your Permanent Mailing Address, including a P.O. Box if necessary, to receive correspondence from the Department of Health.
Upload a legible Copy of your Driver’s License or Identification that includes your Date of Birth.
Attach a Copy of your Social Security Card as required.
Finally, upload a Copy of your current, active certification(s), ensuring it is in good standing before submission.
Start filling out the form online for free today and streamline your application process!
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