Change Font Size:

License Information

Please select the discipline in which you are eligible to be registered in and wish to apply for licensure. If you select other you must contact the Board office prior to submitting the application.

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 complete the following information.

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.

Mailing Preference



Page Updated: 6/4/2018 2:08:37 PM