Perfusionist

​​​ ​​​​Now Live: Easier Online License Applications!

LicensE, our new, online, self-guided occupational license application platform is now live! The list of licenses available via LicensE is available HERE​.  Starting on May 16, 2022, those applicants can apply at license.wi.gov.​

LicensE is for new, initial applications only. To renew your license, click HEREYou should not use LicensE to renew your license at this time.​


For additional information, please see the LicensE User Guides and Video page. ​Check back for updates, FAQs, and application tips.

​License Information

Per Wis. Stat. § 440.08 (2), the required renewal date for the Perfusionist credential is 02/28/ or 29/even years.  Should you receive your initial credential in the months leading up to this date, you are still required to renew your license by the statutorily defined date.


Pre-Credential Education Information

Graduate from a medical board approved perfusion school.

Certification from the American Board of Cardiovascular Perfusion.


Application for Licensure

FormDescription
2562 Credentialing Information for Perfusionist Applicants
​3217​Application for Fee Reduction (If applying for a fee reduction, this form must accompany Form #2562.)
2564Perfusionist Certificate of Professional Education
2565Perfusionist Employment Verification Form
2566​Request for Temporary License for a Perfusionist
​2567​Request for Verification of Certification
2829 Malpractice Suits or Claims Form (if applicable)
​3085​Application for Predetermination (Optional-Submit ONLY if you have been convicted of any felony, misdemeanor, or other violations of federal or state law in this state or any other and you desire a review of your conviction record before applying for a credential.)
2252 Convictions and Pending Charges
3071Fax Payment Form

Renewal Information

Requirements

  • FEE (See Renewal Dates and Fees)
  • SIG (Signature regarding the completion of Continuing Education, included in on-line renewal and paper form see Continuing Education Information for details)
  • If your legal status as a qualified alien or nonimmigrant lawfully present in the United States has changed since the issuance of your credential or your last renewal, please contact the Wisconsin Department of Safety and Professional Services at (608) 266-2112 or dsps@wisconsin.gov.

Renewal Methods

FormDescription
RDAFRenewal Dates and Fees
R210Active Duty/Discharge Renewal Extension
​​2254
​Convictions and Pending Charges​

Wisconsin Act 210 (effective June 1, 2012)

This Act extends the license of a service member if the license expires while they are on active duty from 90 days to 180 days from the date of discharge. The same applies to a spouse of a service member if the spouse does not practice under their license while the service member is on active duty and does not practice because the service member is on active duty.

This Act repeals a provision of prior law that required a service member to meet all of the requirements for license extension or renewal, except for continuing education requirements, in order to have the license extended.

Service members and spouses may request extensions of licenses beyond 180 days from discharge and may request a waiver or extension of time to complete continuing education requirements due to hardship. Please view Active Duty/Discharge Renewal Extension Form #R210.