Get Print Completed Application 14-2025

This guide provides clear, step-by-step instructions for completing the Print Completed Application online. By following these guidelines, you can ensure that your application is filled out accurately and efficiently.

Follow the steps to fill out your application correctly.

1. Press the ‘Get Form’ button to download and open the form in your editor.
2. Begin by filling out the personal data section. Provide your full name, home address, and contact information. Ensure no fields are left blank and use 'N/A' for non-applicable items.
3. Complete the current practice information. Provide details about your primary office and any additional locations. List the contact information for the office manager.
4. In the licensure section, list all current professional licenses. Attach readable copies of each license and ensure the details are accurate.
5. Input your education history in the education section. Include all relevant degrees and training, and be specific — do not use 'See CV'.
6. Fill out the post-graduate training section with details of your training relevant to your practice. Provide the type of training, program director, and dates.
7. Complete the military/public health service section if applicable and attach your DD-214 if necessary.
8. In the work experience section, provide a thorough account of your past fifteen years in healthcare. If additional space is required, use the provided addendum.
9. List all healthcare affiliations and detail any terms or reasons for leaving. Ensure all previous associations are included.
10. Identify your board certification status. Provide documentation if applicable and detail any continuing medical education related to your practice.
11. Attach copies of all required documentation as specified in the instructions. This includes licenses, education certificates, malpractice insurance information, and more.
12. Once all fields are filled, review the application for completeness. Save your changes, then proceed to download, print, or share your completed application.

Complete your Print Completed Application online today for efficient processing.