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This guide provides clear, step-by-step instructions for completing the application for a general anesthesia permit online. By following these instructions, you can accurately fill out the required information and ensure your application is properly submitted.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin with the identifying information section. Fill in your last name, first name, middle name, license number, specialty license number, D.E.A. number, and birth date. Ensure all information is accurate and up-to-date.
3. Provide your primary office address, including street address, city, state, zip code, and telephone number. Repeat this process for your second office and home address if applicable.
4. In the education section, list your educational background, including the names of institutions attended, degrees earned, and dates of attendance. Detail any relevant training or certifications.
5. Answer the questions regarding your training and education criteria. Select all relevant categories that apply to you and provide any necessary documentation as indicated.
6. Document any history of general anesthesia use prior to July 1, 1987, if applicable. Summarize your qualifications in a detailed résumé focusing on your general anesthesia training and experience.
7. List your current and past hospital affiliations along with status and appointment dates. Be thorough and ensure accuracy.
8. Indicate any licenses held from other states, along with their respective license numbers and dates of issue.
9. Provide details regarding any mortality or morbidity instances related to your use of anesthesia. Use a separate sheet if necessary.
10. Detail your outpatient facility's anesthetic techniques and major drugs employed for sedation.
11. Attach a separate sheet listing your auxiliary staff along with their CPR certification dates.
12. In the practice history section, list your professional experiences in chronological order, including military service.
13. Respond to questions about prior disciplinary actions or hospital privileges and provide details if necessary.
14. Complete the continuing dental education section by listing professional meetings and seminars you have attended in the past two years.
15. Review your application for completeness and accuracy. Ensure all information is truthful to the best of your knowledge.
16. Print the completed application, sign and date where indicated, and prepare to submit it along with the necessary documents and fees.
17. Finally, save the changes, download, print a copy for your records, and share the form with the appropriate Board office.

Begin completing your general anesthesia application online today.