Licensure Forms

The forms on this page were created using Adobe Acrobat. They are best viewed with that software or Acrobat Reader. If your browser does not support this feature, please save the document to your local computer and then open it directly in one of the Acrobat applications. Adobe Acrobat Reader is available at no charge from Adobe (click the Get Adobe Acrobat Reader link below to download the software):

Get Adobe Acrobat Reader

Forms noted as "Fillable" have fields that can be directly typed into on the computer, and the data can be saved and sent along with the form. If your computer does not display these correctly, or if you prefer to print the forms out and write or type in the information, non-fillable versions have been provided for your convenience.


Athletic Trainer (A.T.)

Certified Nurse Midwife (C.N.M.)

Contact Lens Distributor

Doctor of Chiropractic Medicine (D.C.)

Doctor of Medicine and Surgery (M.D.)

Doctor of Naturopathic Medicine (N.D.)

Doctor of Osteopathic Medicine and Surgery (D.O.)

Doctor of Podiatric Medicine (D.P.M.)

Licensed Acupuncturist (L.Ac.)

Occupational Therapist (O.T.)

Occupational Therapy Assistant (O.T.A.)

Physician Assistant (P.A.)

Physical Therapist (P.T.)

Physical Therapy Assistant (P.T.A.)

Radiologic Technologist (L.R.T.)

Respiratory Therapist (R.T.)