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License Information

Please select discipline(s) in which you are currently REGISTERED and wish to practice and apply for licensure: (if practicing in more than one modality MUST have the appropriate registry in EACH modality – ND state law)

Please select the applicable application type. If you select endorsement, please list ALL states currently licensed in the textbox provided.

Personal Information

Please complete the following information.

(Failure to provide your social security number is a basis to deny a license. Federal law, 42 U.S.C. § 666(a)(13)(A), requires state professional and occupational licensing authorities to obtain all applicants' social security numbers and report these numbers to the state's child support enforcement authority. We will keep your social security number confidential, except when required to provide it according to state or federal law.)

U.S. Citizen

(8 U.S.C. §1621 requires proof of legal presence in the United States. Acceptable documents include a copy of your birth certificate, or Social Security Card, US passport, foreign VISA or permission to work in the US. A driver's license is NOT an acceptable document to show citizenship. If you have alien status, please contact the Board office for additional acceptable documents.)

Contact Information

Please provide your mailing address information below. (This is the mailing address where the Board office will send your Criminal History background check forms and eventually your license.)

Employer Information

Please only complete this section if you are employed as an Imaging Professional. If you are not currently employed, this section can be provided at a later date by using the online change of information form.

Locum Tenens (Travelers)

Locum Tenens is one filling an office for a time or temporarily taking the place of another due to an absence, illness or shortage of employees. This can include traveling to another city/town or to a different state.

Are you currently working as a locum tenens?
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Page Updated: 5/18/2018 4:15:28 PM