Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction outside the U.S. and its territories.
This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.
- Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction outside the U.S. or its territories in which you are or have been licensed/certified. Be sure to sign and date item 10.
- Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.
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