PA

Instructions

Screen Guide

Demographics

Background Information

Education/Training/Experience

Examination/Current Practice Information

Certification of Licensure in Other States

List A

List B

Citizenship-U.S. Citizenship or National Status

Citizenship Declaration

Certification and Release

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

Affirm And Submit

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)

  

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)

  
  
Please note that after you click the Submit button, you cannot make changes to your application.

P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116