Loading
Get 3473312218 Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the 3473312218 Form online
This guide provides a comprehensive overview of how to complete the 3473312218 Form online, ensuring that you can efficiently and accurately submit your notification of change as a physician assistant. Follow the instructions closely to ensure your application is successful.
Follow the steps to fill out the 3473312218 Form seamlessly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering your full legal name as it appears on your driver’s license, Social Security Card, etc., in the designated fields for Last Name, First Name, and Middle Name.
- Provide your Social Security Number and Maiden Name, if applicable. Remember that your Social Security Number is confidential and must be included for processing.
- Certify your citizenship status by checking the appropriate box, indicating whether you are a citizen, a qualified alien, or a foreign national. If you are a foreign national, ensure you understand the requirement to visit DOPL’s offices with proper identification.
- Complete the section regarding your valid Driver License or State Issued ID by providing the state and license number, or stating if you do not have a driver license.
- Input your mailing address, city, state, ZIP code, date of birth, phone number, and email address accurately.
- List any supervising physicians you wish to remove and provide their names and license numbers. If none are being removed, you may indicate that current physicians will remain as supervisors.
- If applicable, list substitute supervisors, providing their names and license numbers as required.
- Complete the summary section listing your supervising physicians to remain and to be approved, ensuring you use additional sheets if necessary.
- Fill out the affidavits for both the supervising physician(s) and the physician assistant. Each person must sign and date where indicated.
- Review all entries for accuracy. Once completed, save your changes and choose to download, print, or share your form as needed.
Start filling out your 3473312218 Form online today to ensure timely processing.
To file Form 10IEA, begin by gathering all relevant financial documentation and understanding the required disclosures. Complete the form according to the guidelines, ensuring all information is accurate. The 3473312218 Form can simplify this process by helping you organize your details systematically before submission.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.