Applications/Forms

The following forms are in Adobe Acrobat Reader.  Click the following link to download a free version of Adobe Acrobat Reader.

If you have not completed and submitted the on-line CLAF application from the link above, you may not use the following forms.  These forms are provided as duplicates only.

Temporary Permit Request Form 

Release and Waiver Form (PDF 10KB)

Form 1 - Licensure Verification Form (PDF 11KB)

Addendum 4 - Hospital/Clinic List (PDF 19KB)

Addendum 4A - Hospital/Clinic Affiliation Form (PDF 18KB)

Addendum 5 - Physician Reference Form (PDF 68KB)

Addendum 6 - HIV/AIDS Affidavit of Reasonable Cause (PDF 21KB)

Addendum 7 - CME Report Form (PDF 15KB)

FBI Criminal Background Check Information and Request Form (PDF 21KB)

American Medical Association Profile Request

American Osteopathic Association Profile Request

National Practitioner Data Bank Query Request