Registration Form

Application to Practice Medicine without LIC

Please note: The questions and answer options in this form are determined by state and federal government. For a successful submission, we may not change the questions or the answer options.

* First Name:

* Last Name:

* Phone Number:

Current Address:

* Address – Street Number:

* Address – Street Name:

Address – Apartment/Suite:

* City Name:

* State:

* Zip Code:

* Email:

Description:

Place of Birth:

Country of Citizenship:

* Date of Birth:

Gender:

Race:

Height:
feet
inches

Weight: pounds

Eye Color:

Hair Color:

CJIS Reference Number:

Type of Payment:

Payment Amount: $ and cents

Background Data

Position Applied For:

* Authorization Number:

* Originating Agency Identifier:

Request Type:

Convition / Probation?

Pending Criminal Charges:

Child Care Administration Authorization #:

State Driver's License:

Driver's License #:

Customer Amount of Payment: $ .

Reason Fingerprinted:

* Payment Policy

After clicking submit, you will be directed to a confirmation page. Click the button on the confirmation page for instructions on how to arrive to your appointment. Please initial below to agree to our refund policy. Refunds are not available based on missed appointments. Refunds are not available based on customer errors in the registration form that need correction. Customers will be given the opportunity to reschedule and/or to correct registration forms at no additional charge.

Online Registration
Maryland & Federal
Background Checks

Application to Practice Medicine without LIC

Current Address:

Description:

Background Data

Phone:

Address:

Get Started

Pages

Online Registration Maryland & Federal Background Checks

Application to Practice Medicine without LIC

Current Address:

Description:

Background Data

Phone:

Address:

Get Started

Pages

Online Registration
Maryland & Federal
Background Checks