Department of public health and social services 2026

1. Click ‘Get Form’ to open the license application in the editor.
2. Begin with Part I: Applicant Information. Fill in your last name, first name, middle name, suffix, and social security number. Ensure your mailing and residence addresses are accurate.
3. Provide details about your most recent employment, including the employer's name, address, and your position title along with employment dates.
4. In Part II: Educational Information, list all secondary and post-secondary institutions attended. Include graduation dates and degrees earned.
5. Complete Part III: Licensure Information by detailing any previous licenses held. Be thorough to avoid application denial.
6. Answer all questions in Part V: Personal Practice History Information honestly. Any 'Yes' responses require detailed explanations on a separate sheet.
7. Finally, review all sections for accuracy before signing the certifying statement at the end of the form.

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