Applications and Forms
- New Applications & Forms Notice
- Full Licensure Application
- Submit this application if you are currently certified by NCCPA.
- Temporary Practice Certificate Application (PDF)
- Use this application if you have graduated from a PA program but have not yet taken the NCCPA certifying exam.
- Supervising Physician Form for Temporary Practice Certificates and Full Applications
- Work Setting Form for Temporary Practice Certificates and Full Applications
- Change of Supervising Physician
- Use this form to report the following:
- replacing your current supervising physician OR
- adding an additional supervising physician OR
- terminating a supervising physician
- Change of Work Setting Information
- Use this form if you are currently licensed and need to report a change or addition in work setting.
- National Commission on Certification of Physician Assistants (NCCPA) Release Form (PDF)
- Use this for to request release of national certification examination scores.
- Online Renewal, Change of Address and Duplicate License
- Change of Address or Name and/or Request for Duplicate License (PDF)
This information is provided by the Division of Health Professions Licensure within the Department of Public Health.