Provide the necessary personal information
in the fields to the right. All fields with (*) are required and must be
completed to continue the application process.
Title
First
Name
Middle
Name
Last
Name
Maiden
Name
Social
Security Number
Date of
Birth
Email
Address
Phone
Number
Cell
Phone/Mobile Number
Other
Phone Number
Provide the necessary additional
information in the fields to the right. All fields with (*) are required and
must be completed to continue the application process.
If you were born in the United
States, you will need to list the city and state where you were born.
Do you have other aliases?
Please list all other aliases.
What is your gender?
In
which country were you born?
In which state were you born (if United States)?
In which city were you born?
Please choose a mailing address
from the dropdown options (this is the address used for all postal
communications from the Board for this license). To add a new address, click on
ADD ADDRESS, fill out the necessary fields, and then click Save. To remove an
address, click on DELETE ADDRESS and select the delete icon next to the address
you wish to remove.
Please choose a public license
mailing address from the dropdown options (this is the address that will be
viewable by the public). To add a new address, click on ADD ADDRESS, fill out
the necessary fields, and then click Save. To remove an address, click on
DELETE ADDRESS and select the delete icon next to the address you wish to
remove.
List all states and/or
jurisdictions in which you have ever held a health-related license. To add a
license you currently hold or previously held, click the Add License button.
Complete the information fields and click Save. All fields marked with (*) are
required. Repeat this process for each additional license you hold or held. To
edit an added license, click the pencil icon.
Answer the following questions
Yes, No, or N/A if it doesn't apply to you. Any answer that requires an
explanation will be on the Uploads section of this application. Once completed,
click "Save and Continue" to progress through the application.
Question - Are you on active
military duty in Ohio?
Question - Is your spouse on
active military duty in Ohio?
Question - Has any board, bureau,
department, agency, or other body in any way limited, restricted, suspended, or
revoked any professional license, certificate or registration granted to you;
placed you on probation; or imposed a fine, censure or reprimand against you?
If yes, please attach supporting documentation and an explanation of the
circumstances that resulted in the disciplinary action.
Question - To the best of your
knowledge, are you currently under investigation by the licensing agency of any
state or jurisdiction? If yes, please attach supporting documentation and an
explanation of the circumstances that resulted in the investigation.
Question - Have you ever pled
guilty to, been found guilty of a violation of any law, or been granted
intervention or treatment in lieu of conviction regardless of the legal
jurisdiction in which the act was committed, other than a minor traffic
violation? If yes, please attach supporting documentation and an explanation of
the incident in your own words.
If applicable, upload the
Attachments for your license application by clicking the Add Attachment button(s).
If uploading an attachment as a submission, it is necessary that the name of
the file attachment is less than 80 characters in length for it to be received
successfully. The character limit does include the file attachment extension,
such as (.doc) and (.pdf). The (.exe) and (.html) file extensions are not
supported for submissions. For documentation that needs to be submitted
directly to the Board or by hardcopy, please acknowledge by clicking the Attest
button(s). If no attachment or attestation items appear, please click the Save
and Continue button.
Out of
State License Certification
Description - I attest that I
will request a certification letter be sent from each of the state board(s)
where I hold or have held a professional license/certificate.
Proof of Military Duty
Description
- Please upload proof that you or your spouse is on active military duty in
Ohio. Military duty includes service in the uniformed services on active duty,
in the active guard and reserve, and as a military technician dual status under
10 U.S.C. 10216.
Once the
review has been processed, the license application will be completed.
Application Review -
I acknowledge that I will
immediately inform the board if a license or certificate issued by another
state or jurisdiction expires or is revoked, or I am no longer in good
standing.
If this application is based upon
my spouse being on active duty in Ohio, I acknowledge that I will inform the
board within six months of divorce, dissolution, or annulment of the marriage.
I hereby certify and attest that
I am the person named in this application, that all statements I have or shall
make with respect thereto are true, that I am the original and lawful possessor
and person named in the various forms and credentials furnished or to be
furnished with respect to my application and that all documents, forms or
copies thereof furnished or to be furnished with respect to my application are
strictly true in every aspect.
I
acknowledge that I have read and understand this application and have answered
all questions contained in this application truthfully and completely. I
further acknowledge that failure on my part to answer questions truthfully and
completely may lead to my being prosecuted under appropriate federal and state
laws.
I authorize and request every
person, government agency (local, state, federal or foreign), court,
association, institution or law enforcement agency having custody or control of
any documents, records and other information pertaining to me to furnish to the
Board any such information, including documents, records regarding charges or
complaints filed against me, formal or informal, pending or closed, or any
other pertinent data and to permit the Board or any of its agents or
representatives to inspect and make copies of such documents, records, and
other information in connection with this application.
I hereby release, discharge and
exonerate the Board, its agents or representatives and any person, government
agency (local, state, federal or foreign), court, association, institution or
law enforcement agency having custody or control of any documents, records and
other information pertaining to me of any and all liability of every nature and
kind arising out of investigation made by the Board.
I will immediately notify the
board in writing of any changes to the answers to any of the questions
contained in this application if such a change occurs at any time prior to the
credential for which I have applied being granted to me by the board.
I
understand my failure to answer questions contained in this application
truthfully and completely may lead to denial, revocation, or other disciplinary
sanction of the credential for which I have applied.
Consent to Electronic Signature
Date/Time Stamp
Type your First Name and Last
Name as they appear on the application to sign electronically.
Submit
your Application -After clicking the ‘Submit’ button below, you will no longer
be able to change this application.
PLEASE
DO NOT USE THE BROWSER'S BACK BUTTON AS THAT MAY OVERWRITE
YOUR DATA.
If this application requires
payment you will be prompted to begin the payment process. You must complete
the payment process before the board will review your application. If this
application does not require payment, you will be navigated back to the eLicense
home page and the board will review your application.