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HRLA Health License Application Form

The following web form is designed to allow health License Application applicants to submit an application to DOH for license approval. This would replace the current paper form in use.

Section 1. LICENSURE TYPE &FEE

Yes

Licensure by Endorsement

Yes

Section 2A. APPLICANT INFROMATION

First Name

Last Name

Suffix

Date of Birth

Gender

Male

Female

Bisexual

Place of Birth

Country

Section 2B. OTHER NAMES USED

First Name

Last name

Suffix

Section 2C. RACE & ETHNICITY DESIGNATION

Language spoken

Section 3A. HOME

Address

Apartment #

Phone Number

Fax

Cell Phone

Email Address

Section 3B.BUSINESS ADDRESS

Address

Apartment #

Phone Number

Fax

Cell Phone

Email Address

Section 3C. NURSING SCHOOLS ATTENDED

School Name

City

State

Country

Date of Graduation

Degree

Section 3D. PROFESSIONAL LICENSURE IN OTHER JURISDICTION

Original Licensure

Current license

Jurisdiction

Active / Not Active

License Number

Section 4. SUPPORTING DOCUMENTS REQUIRED

Passport-type photos

Copy of legal document

SSN Affidavit Form

Verification of licensure status

International applicants educated outside of the US or its territories

Yes

Provide a detailed explanation

Section 5. SCREENING QUESTIONS

Clean Hands Before Receiving a License

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HRLA Health License Application Form