Complete at least the information in shaded areas; sign and date the application in ink; only origin 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out all shaded areas, including your Last Name, First Name, Middle Initial, and other personal details such as Social Security Number and Date of Birth.
3. Indicate if there is a change of address by selecting 'Yes' or 'No' and provide the updated information if applicable.
4. Complete the Statement of Continuing Education on the second page, ensuring you list all required courses along with their dates and CE hours.
5. Review your answers carefully. Once satisfied, sign and date the application in ink. Remember that only original signatures are accepted.
6. Finally, ensure you have included any necessary attachments regarding criminal history or certification issues before submitting your application.

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