Apply for a provisional perfusionist license

• Social Security Number SSN
• Date and place of birth
• Mother's maiden name
• A 2x2 color passport photo
• A notary signature
• Official transcripts in signed, sealed envelopes for all perfusionist programs/degrees. When requesting official transcripts, please inform each school’s registrar that the transcript must be complete and state the degree and date conferred in mm/dd/yyyy format. The institutions must send transcripts directly to the Board.
  • Note: If transcripts have been previously submitted with an application for Provisional License, they don't need to be sent again if they were sent in the past 12 months
• American Board of Cardiovascular Perfusion (ABCP) documentation that you:
  • Have met all the requirements for licensure as a perfusionist set forth in 267 CMR 3.04, except passing of the perfusionist certification examination administrated by ABCP
  • Are registered for, and have been determined to be eligible to take, the next available administration of the perfusionist certification examination administrated by ABCP
  • The ABCP must send the documentation directly to the Board. Email verifications are not acceptable.
• Supervisor information
  • A licensed perfusionist who holds a current, valid MA license to practice perfusion must agreed to serve as your supervising perfusionist
  • They must complete the Supervisor Information section of the application (page 5)
  • They will sign and date the statement that they agree to serve as the your supervising licensed perfusionist and will provide supervision as required by 267 CMR 3.06(6) and Board Policy PF-10-01
  • Statement must include the perfusionist’s full name, business address, license number, and signature
• Submission of the Criminal Offender Record Information Request Form (CORI)

If applicable

• Verification of licensure status, in signed, sealed envelopes, from any state or jurisdiction in which you now or have previously held any professional license. The state or other jurisdictions must send verifications directly to the Board.
• If you hold, or have ever held, any professional license, you must request and submit a National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Self-Query. To request a Self-Query, please contact the National Practitioner Data Bank. Include the original report with this application. Make a copy for your records.
  • Note: If you don't hold and have never held any professional licenses in any other state or jurisdiction, you don't need to submit a National Practitioner Data Bank self-query
• If you answer "yes" to any of the questions 11-16:
  • Attach a separate sheet explaining the circumstances

The address printed on your license is a public record that is available to anyone who requests it. If you are using your home address, you may wish to consider changing this to an office address. You may request address changes online at the board’s website, or you may get a form online to submit to the Board’s office.