:: Initial Applications ::

Instructions

Application for Licensure of Physician Assistant (P.A.)

It is the responsibility of the P.A. to submit an application in a timely manner to ensure it is received and reviewed by the Board within the intended month. Click here to access the Board’s agenda deadline schedule.

Before you begin, you should thoroughly read Board Rules, Chapter 540-X-7, Assistants to Physicians. Click here to read the rules.

Both a state license and a registration agreement to a supervising physician are required to practice as a physician assistant in Alabama.

Presently, an initial license and registration agreement may be obtained at the same time. Although licensing is a one-time process, a registration agreement is required for each new professional relationship.

Before you begin this application, review the list below and ensure you have each of the required documents and available funds. Once you begin the application process, you will not have the opportunity to save and complete the application at a later time. Please ensure you have what is required before you begin.

The following items are required to complete the online application:
1) Diploma reflecting graduation from an approved P. A. training program (Transcripts are not acceptable)
2) NCCPA certificate/certification of successful completion of the examination
3) Funds of $265.00 for the payment of the license fee and the criminal history background check
4) Supporting documentation for Declaration of Citizenship; click here to view a list of valid documents
5) Color photograph taken within sixty days prior to the date of this application

Fingerprint Card Request
You must request fingerprint cards for your criminal background check. Send an email to [email protected].. Please be sure to include your mailing address in your email request. You must also submit the Application To Review Alabama Criminal History Record Information to conduct your criminal background check. This form should be mailed to the Board along with your two completed fingerprint cards. Click here to obtain the required form.

Note:
Waiting to receive information from another entity can cause delays in a licensure application being placed on the Board's agenda (i.e., license verification from other states, copy of a diploma, and criminal background results).

Screen Guide

Screen Layout

Reviewing Completed Application

cannot

Printing Application

Demographics

First Name

Middle Name

Last Name

Alternate Name(s)

SSN

Date Of Birth

Email Address

Home Telephone Number

Work Telephone Number

*Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete and no license will be issued.

Place Of Birth

Country of Birth

State/Province of Birth

City of Birth

Gender/Sex (at birth)

Contact Information

The address and contact methods provided should be how the Board can contact the license applicant directly. Please DO NOT provide contact information for office managers, assistants, or license assistance companies.

Home Address

Country

Street

Apt/Suite

City

State

Zip Code

County

Examination/Current Practice Information

Have you successfully completed the Physician Assistant National Certifying Examination?

Yes

Are you currently registered, certified to or working for any other primary supervising physician in another state? i.e. Are you presently working as a physician assistant? If so, answer yes.

Yes

List A

DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP

(1) The applicant's driver's license or nondriver's identification card issued by the division of motor vehicles or the equivalent governmental agency of another state within the United States if the agency indicates on the applicant's driver's license or nondriver's identification card that the person has provided satisfactory proof of United States citizenship.

(2) The applicant's birth certificate that satisfactorily verifies United States citizenship.

(3) Pertinent pages of the applicant's United States valid or expired passport identifying the applicant and the applicant's passport number.

(4) The applicant's United States naturalization documents or the number of the certificate of naturalization

(5) Other documents or methods or proof of United States citizenship issued by the federal government pursuant to the Immigration and Nationality Act of 1952, and amendments thereto.

(6) The applicant’s Bureau of Indian Affairs card number, tribal treaty card number, or tribal enrollment number.

(7) The applicant’s consular report of birth abroad of a citizen of the United States of America.

(8) The applicant’s certificate of citizenship issued by the United States Citizenship and Immigration Services.

(9) The applicant’s certification of report of birth issued by the United States Department of State.

(10) The applicant’s American Indian card, with KIC classification, issued by the United States Department of Homeland Security.

(11) The applicant’s final adoption decree showing the applicant’s name and United States birthplace.

(12) The applicant's official United States military record of service showing the applicant's place of birth in the United States.

(13) An extract from a United States hospital record of birth created at the time of the applicant's birth indicating the applicant's place of birth in the United States.

List B

DOCUMENTS INDICATING STATUS OF QUALIFIED ALIENS, NONIMMIGRANTS, AND ALIENS PAROLED INTO U.S. FOR LESS THAN ONE YEAR

The documents listed below that are registration documents are indicated with an asterisk (“*”).

a. “Qualified Aliens” Evidence of “Qualified Alien” status includes the following:
Alien Lawfully Admitted for Permanent Residence
  • Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
  • Unexpired Temporary I-551 stamp in foreign passport or on * I Form-94.
Asylee
  • * Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
  • * Form I-688B (Employment Authorization Card) annotated “274.a12(a)(50”;
  • * Form I-766 (Employment Authorization Document) annotated “A5”;
  • Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or
  • Order of an immigration judge granting asylum.
Refugee
  • * Form I-94 annotated with stamp showing admission under § 207 of the INA;
  • * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or
  • * Form I-766 (Employment Authorization Document) annotated “A3”
Alien Paroled Into the U.S. for at Least One Year
  • * Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one year requirement.)
Alien Whose Deportation or Removal Was Withheld
  • * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10);
  • * Form I-766 (Employment Authorization Document) annotated “A10”; or
  • Order from an immigration judge showing deportation withheld under §243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under § 241(b)(3) of the INA.
Alien Granted Conditional Entry
  • * Form I-94 with stamp showing admission under §203(a)(7) of the INA;
  • * Form I-688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or
  • * Form I-766 (Employment Authorization Document) annotated “A3.”
Cuban / Haitian Entrant
  • * Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6;
  • Unexpired temporary I-551 stamp in foreign passport or on * Form I-94 with the code CU6 or CU7; or
  • Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA.
Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty
  • U.S. Citizenship and Immigration Service petition and supporting documentation

Citizenship-U.S. Citizenship or National Status

Are you a citizen or national of the United States?

Yes

Citizenship Declaration

I understand and agree that by typing my name, I am providing an electronic signature that has the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing information has been provided by me and is true and correct to the best of my knowledge, information and belief.

I declare under penalty of perjury under the laws of the State of Alabama that the answers and evidence I provided are true and correct to the best of my knowledge.

Applicant's Signature

Date

Certification and Release

certify that all of the information supplied in the submitted application is true and correct to the best of my knowledge, that the photograph submitted herein is a true likeness of me and was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue statement or representation made in this application may result in the denial of this application or revocation of any certification/licensure granted.

I further consent to and authorize the release of this application and any information submitted with it or information collected by the Alabama Board of Medical Examiners in connection with this application, including derogatory information, to any person or organization having a legitimate need for the information, and I release the Alabama Board of Medical Examiners from all liability for the release of this information. I further consent to and authorize the release of information, including derogatory information, which may be in the possession of other individuals or organizations to the Alabama Board of Medical Examiners, and I release this person or organization from any liability for the release of information.

Under Alabama law, this document is a public record and will be provided upon request.

The Alabama Board of Medical Examiners will enforce the Board’s rules and option for the issuance of a Non-Disciplinary Citation and Administrative Charge when an applicant falsifies an application.

Date

Physician Assistant’s Signature

Upload a color photograph taken within sixty days prior to the date of this application.

Review Page – If everything is correct, press “Next”

Scroll down to review application. If everything is correct, press "Next"

Affirm And Submit

Payment Deferral

Date :

Fee

E-Signature

Payment Type

Person’s Name on Card

Card Type

Person's Name on Account

Card #

Expiration Date (MM/YY)

Security Code

Routing Number

Account Number

Account Type

Billing Zip

Board of Medical Examiners charge will appear on your statement with a description including IGOVSOL*

When entering attendance dates below, you may use the first date of the month instead of the exact date. (Ex: attended August 1990 – July 1994, enter 08/01/1990 – 07/01/1994)

School Name

Start Date

End Date

School Address

When entering attendance dates below, you may use the first date of the month instead of the exact date. (Ex: attended August 1990 – July 1994, enter 08/01/1990 – 07/01/1994)

N/A

Place of Employment or Activity

Start Date

End Date

Country

Street Address

Suite

City

State

Zip Code

First Name

Last Name

Practice Location Address

Street

Apt/Suite

City

State

Zip Code

Hours Per Week

Phone Number

Email Address

Alabama	Alaska	Alberta	American Samoa	Arizona
Arkansas	Armed Forces Americas	Armed Forces Canada	Armed Forces Europe (FPO)	Armed Forces Pacific (APO)
British Columbia	California	Canada	Colorado	Connecticut
Delaware	District of Columbia	Fed St Micronesia	Florida	Georgia
Guam	Hawaii	Idaho	Illinois	Indiana
Iowa	Kansas	Kentucky	Louisiana	Maine
Manitoba	Marshall Islands	Maryland	Massachusetts	Michigan
Minnesota	Mississippi	Missouri	Montana	Nebraska
Nevada	New Brunswick	New Hampshire	New Jersey	New Mexico
New York	Newfoundland	North Carolina	North Dakota	Northern Mariana Island
Northwest Territories	Not Known	Nova Scotia	Nunavut	Ohio
Oklahoma	Ontario	Oregon	Other Country	Palau
Pennsylvania	Prince Edward Island	Puerto Rico	Quebec	Rhode Island
Saskatchewan	South Carolina	South Dakota	Tennessee	Texas
Unknown	Utah	Vermont	Virgin Islands	Virginia
Washington	West Virginia	Wisconsin	Wyoming	Yukon

Alabama	Alaska	Alberta	American Samoa	Arizona
Arkansas	Armed Forces Americas	Armed Forces Canada	Armed Forces Europe (FPO)	Armed Forces Pacific (APO)
British Columbia	California	Canada	Colorado	Connecticut
Delaware	District of Columbia	Fed St Micronesia	Florida	Georgia
Guam	Hawaii	Idaho	Illinois	Indiana
Iowa	Kansas	Kentucky	Louisiana	Maine
Manitoba	Marshall Islands	Maryland	Massachusetts	Michigan
Minnesota	Mississippi	Missouri	Montana	Nebraska
Nevada	New Brunswick	New Hampshire	New Jersey	New Mexico
New York	Newfoundland	North Carolina	North Dakota	Northern Mariana Island
Northwest Territories	Not Known	Nova Scotia	Nunavut	Ohio
Oklahoma	Ontario	Oregon	Other Country	Palau
Pennsylvania	Prince Edward Island	Puerto Rico	Quebec	Rhode Island
Saskatchewan	South Carolina	South Dakota	Tennessee	Texas
Unknown	Utah	Vermont	Virgin Islands	Virginia
Washington	West Virginia	Wisconsin	Wyoming	Yukon