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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.
List all states you are currently licensed in and include the license number below.
Select the add button to add additional other state license information.
If "yes", you must submit proof of active member status. Appropriate proof is a military issued ID.
If "yes", you must submit proof of a spouse of active member status. Appropriate proof are a military issued ID noting relationship to the military member and the orders of the active military member spouse.**If you are a spouse of an active military member, you are not required to pay the fee. As defined in NDCC 43-51-01(5), a military spouse is one who is currently licensed in another state or jurisdiction and who is the spouse of a member of the armed forces of the United States or a reserve component of the armed forces of the United States stationed in this state in accordance with military orders or stationed in this state before a temporary assignment to duties outside of this state.
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.)
(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.)
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.)
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 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.
Please provide the information below.