Get Disclosure In Relation To Your Application For Practitioner Status

Filling out the DISCLOSURE in relation to your application for practitioner status is a crucial step in ensuring that your background is thoroughly reviewed. This guide provides clear and supportive instructions to help you navigate the form easily.

Follow the steps to complete the disclosure form online.

1. Click ‘Get Form’ button to access the form and open it in your selected editor.
2. Begin filling out your current name in the designated field. If you have had previous names, such as a maiden name, include those as well, using additional paper if necessary.
3. Enter your complete address in the provided fields, avoiding the use of P.O. Boxes. Ensure to include your city, state, zip code, and county.
4. Provide your daytime and evening phone numbers along with an email address where you can be reached.
5. Input your Social Security number and date of birth. This information is significant for the background check process.
6. Indicate your gender by selecting the appropriate option.
7. Next, state whether the prospective facility may contact your current employer by selecting 'yes' or 'no'.
8. Fill in the required details matching how your name appears on your driver’s license, along with your driver’s license number and state of issue.
9. If applicable, include your professional license type, state, number, and expiration date.
10. For the past ten years, list each county and state of your previous places of residence in the designated sections. Use additional paper if needed.
11. Answer the questions about any convictions or pending criminal charges truthfully, providing details as required.
12. Review your responses for accuracy before you complete the 'authorization release' section. Here, provide your signature and date to authorize the background investigation.
13. Finally, save your changes, and download, print, or share the completed form as needed.

Complete your disclosure form online to facilitate your practitioner status application process.