Board of Medicine

Application Request Form

All applications may be found on our website except for the paper renewal application and reinstatement application for licenses that have been inactive for under 12 months. If you are requesting one of these applications, please fill in the information below and submit the information.

Full Name:*
Address 1:*
Address 2:
City, State, Zip:*


Type of application you are requesting:*

Reinstatement of inactive license-under 12 months only


Comments or Questions:

* Check this box if you are ready to submit your request. Then select the submit button below.


return to home page