Tricare South Region Application Form Page 13
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TRICARE
South Region Application
E.
LICENSE/CERTIFICATION INFORMATION
List your current DEA certificate number, if applicable. Be sure to include a current copy of
DEA CERTIFICATES:
your certificate(s) with your application materials.
DEA Certificate #
Exp. Date (mm/yy)
Please identify in the list below, all health care licenses held in the past ten (10) years.
PROFESSIONAL LICENSE(S):
Indicate original licensure date through current expiration date for each state in which you are or have been licensed/certified.
Please provide an explanation for any license that is no longer current, whether by voluntary relinquishment, disciplinary or other
action. Attach an additional sheet if necessary.
Licensing/Certification
State
Specify Active
Certificate #
Original Issue
Expiration Date
(mm/dd/yy)
or Inactive
Date
(mm/dd/yy)
Board Name
List below any certifications you have received
BOARD CERTIFICATION/SPECIALTY (for MDs and DOs only):
from any nationally recognized specialty boards.
Name of Board (if board certified)
PRINCIPAL SPECIALTY
Exam Information (check one):
Oral exam taken
Oral exam scheduled
Written exam taken
Written exam scheduled
No plans to take exam
Exam Date:
Date Certified:
Re-exam Date:
Name of Board (if board certified)
SECONDARY SPECIALTY
Exam Information (check one):
Oral exam taken
Oral exam scheduled
Written exam taken
Written exam scheduled
No plans to take exam
Exam Date:
Date Certified:
Re-exam Date:
ADDITIONAL CERTIFICATIONS (for RNCSs, LPC/LMHCs, PCs and ABA only):
Expiration Date
Certification Type
Certificate #
(mm/dd/yy)
American Nursing Credentialing Center (ANCC) Board Certification (i.e.
APRN, BC)
Fellow/Diplomate Membership of the American Association of Pastoral
Counselors (AAPC)
National Board for Certified Counselors, Inc. (NBCC)
Behavior Analyst Certification Board (BACB). Choose one (1) of the
following:
BCBA
BCBA-D
PRR RECRUITING
Page 12 of 18
Revised 8/04; 10/04; 7/05; 9/05; 11/05; 1/06; 4/06; 6/06; 12/06; 3/07; 5/07;
Provider Application 08-15B
12/10; 7/11; 10/11; 11/11; 8/12; 10/12; 11/12; 02/13; 8/13; 2/14; 6/14; 01/15; 08/15
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