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Certified East Asian Medicine Didactic and Clinical Program: List the name and address of East Asian Medicine Didactic and Clinical Program. Attach an additional page if you need more space. Transcripts must be sent directly to the department. Pre-East Asian Medicine (Basic Science) Education: Provide a chronological listing of your educational preparation and post-graduate training. Another jurisdiction means any other country, state, federal territory, or military authority.
You can get copies of court records through the county courthouse where the conviction, plea, deferred sentence, or suspended sentence was entered. You do not have to answer yes if you have been cited for traffic infractions.
Question 5 includes misdemeanors, gross misdemeanors and felonies. If you do not provide this, your application is incomplete and it will not be considered. You must also provide the documentation listed in the note after the question.
If you answer yes to any questions in this section, you must provide an appropriate explanation. They are focused on your fitness to practice the essential skills of this profession. Personal Data Questions: All applicants must answer the same personal data questions. If you have a name change, you must notify the Department of Health in writing. Other Name(s): Indicate whether you are known or have been known under any other names. See WAC Phone, Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if you have them. This will be your permanent address with Department of Health until we have been notified of a change.
Is my license suspended wa zip#
Be sure to include the city, state, zip code, county, and country. Address: List the address we should use to send any information on your license. Birth place: Provide the city, state, and country where you were born. Birth date: Provide the month, day, and year of your birth. If you use any name other than your legal name on this form, your application may be denied. The court must have the legal authority to change your name. Definition of legal name: Legal name is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court.
Is my license suspended wa full#
Legal Name: List your full name, first, middle, and last. If you have a NPI number, provide this on your application. The NPI is a 10 digit numeric identifier. National Provider Identifier Number (NPI): The National Provider Identifier (NPI) is a standard unique identifier for health care professionals available from the Federal Centers for Medicare and Medicaid Services. Please call the Customer Service Center at if you do not have one. Demographic Information: Social Security Number: You must list your social security number on your application. You can check the fee page for current fees. It is your responsibility to submit the correct required forms. All information should be printed clearly in ink. This may be required if you have lived in another state or if you have a criminal record in Washington State. This check may be through the Washington State Patrol and the Federal Bureau of Investigation (FBI). Box Olympia, WA Contact us: DOH July 2015ģ Application Instructions Checklist Important background check Information: Washington State law authorizes the Department of Health to obtain fingerprint-based background checks for licensing purposes. In order to process your request: Mail your application with initial documentation and your check or money order payable to: Send other documents not sent with initial application to: Department of Health East Asian Medicine Practitioner P.O. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be substituted. If you do not have a social security number at the time you send in this application, please read, complete, and return this form with your application. 1 page Important Social Security Number Information: You are required by state and federal law to provide a social security number with your application.
Is my license suspended wa verification#
1 page Out-of-State Credential Verification Form. 2 pages Application for Licensed East Asian Medicine Practitioner. 1 page Application Instructions Checklist. 1 East Asian Medicine Practitioner License Application Packet Contents: Contents List/SSN Information/Mailing Information.
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