Name *

First Name

Last Name

In regards to my professional license, there is no history of limitation, suspension, revocation, denial, sanctions or under probationary conditions. *

Yes

No

There is no history of my clinical privilege having been limited, suspended, revoked, denied or subjected to probationary condition or sanctions based on my actions, nor by any limitation related to scope of practice either by law or by the restrictions of the health care organization or practice venue. *

Yes

No

There is no history of limitation, suspension, revocation, failure of renewal, sanction or probationary condition imposed in any practice venue related to my behavior or practice. *

Yes

No

There is no history of limitation, suspension, revocation, nonrenewal or probation applied to any professional organization membership except for my own choice to resign from said professional organization. *

Yes

No

I have never been convicted of a felony and there are no felony charges against me pending. *

Yes

No

I have no mental health issues or addiction issues that impair my judgment and practice for patient safety. *

Yes

No

I have no malpractice judgments against me within the last five (5) years. *

Yes

No

I vow to follow and adhere to my professional code of ethics. *

Yes

No