Other Forms and Information

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We are transitioning our forms to an online platform, AccessGov, that meets Americans with Disabilities Act (ADA) guidance. You will be able to submit some forms directly within the platform, while some may require you to print to PDF and upload to another system. Please follow the instructions on each form to ensure proper submission.


​​​​​​​Forms

FormDescription
1051SSN Exempt Form (Only applicable if applying to obtain or renew​ a credential and you do not have a Social Security Number.)
Upload completed form into your LicensE application.
2252​Convictions and Pending Charges
1229​Communicable Disease Form (Only applicable to Health Professions)
​​3217
​Application for Initial Credential Fee Reduction (Optional)
​3085​Application for Predetermination (Optional)
​3071​Payment Form​
​3082​Wall Certificate with Wallet Card or Governor-Signed Wall Certificate Request Form
​LicCo​unts​​Monthly License Counts

Information

TitleDescription
​1907
Disability Modification Request Form for Examinations
​2349​Requests for Modification of Examinations for Persons With Disabilities
2350​Professional Verification of Request for Modification
Military Licensure Benefits​Military Benefits Related to Licensure for Eligible Veterans, Service Members, and Spouses
Death of a Licensee​Procedure for Reporting the Death of a Licensee
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