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Click ‘Get Form’ to open it in the editor.
Begin by filling out 'Part 1: About You'. Enter your last name, first name, middle name, driver's license number, and social security number. Ensure all mandatory fields are completed.
Proceed to 'Part 2: Contact Information'. Input your mailing address, city, state, zip code, cell phone number, home phone number, and both home and work email addresses.
In 'Part 3: Oregon Employer', provide details about your current or prospective employer including their address and supervisor's information.
Complete 'Part 4: Supervising Practitioner' by having your supervising practitioner sign and print their name along with the date.
Fill out 'Part 5: Personal Background History' carefully. Report any prior arrests or convictions as required.
Review 'Part 6: Agreement' and ensure you understand the terms before signing.
Attach any necessary documents for continued education proof as outlined in 'Part 7'.
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