Apply for an initial 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.
• American Board of Cardiovascular Perfusion (ABCP) documentation of certification. The ABCP must send the documentation directly to the Board. Email verifications are not acceptable. You must have both:
  • Attained a passing score on the perfusionist certification examination administered by the ABCP not more than 2 years before the date of your application
  • A certificate as a certified clinical perfusionist issued by the ABCP which is current and valid as of the date of application
• 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.
• Submission of the Criminal Offender Record Information Request Form (CORI)

If applicable

• 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 A: 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.