This application is for students and Doctors who have been practicing less than 24 months. If you are a doctor who has been in practice for 24 months or more, please use the provider application.

You can download the application form here and send it in to us. First, we need you to fill out your name, email address, and phone number below. Also, choose a password to be used for the purpose of checking on the status of your application. We are planning a feature for you to be able to check on the status of your application online using the password you choose.