PRIOR PA/AA LICENSEE (ANY STATE) LICENSURE APPLICATION INFORMATION

PLEASE CLICK HERE FOR SIMPLE CHECKLIST FOR PRIOR LICENSED PA/AA APPLICATION

Here are the two methods you can submit your application and supporting documents:

1. Our EGov Portal: Prior Grad License Application

2. Our Email: [email protected]

APPLICATIONS WILL NOT BE REVIEWED WITHOUT APPLICATION FEE OF $300.00

**PLEASE READ OUR CHECKLIST PRIOR TO FILLING OUT FORMS**

FORM A - AFFIDAVIT OF APPLICANT

FORM A2 - Citizenship Affidavit

FORM AC1 - ADDING AN ALTERNATE

FORM B - REQUEST FOR ADDITIONAL DUTIES

FORM C - ANESTHESIA REFERENCE FORM

FORM D - PRIMARY CARE REFERENCE FORM

FORM E - ANESTHESIA JOB DESCRIPTION

FORM F - PRIMARY CARE JOB DESCRIPTION

FORM H - SEPARATION NOTIFICATION

FORM I - VERIFICATION OF LICENSURE

FORM J - Specific Power of Attorney

FORM K - CERTIFICATE OF EDUCATION

PA/AA Utilization Form