Texas Credentialing Application

Texas Standardized Credentialing Application
Individual Information:
Type of Professional:*
Name:*

First NameMiddle NameLast NameSuffix
Maiden Name:
Years associated with maiden name:
(YYYY-YYYY)
Other Name:
Years associated with other name:
(YYYY-YYYY)
Home Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Home Phone Number:*
Please enter a valid phone number.
Social Security Number:*
Sex:*

FemaleMale
Correspondence Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Correspondence Phone Number:*
Please enter a valid phone number.
Correspondence Fax Number:
Please enter a valid phone number.
Email:*
example@example.com
Date of Birth*

MonthDayYear
Date
Place of Birth:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Citizenship:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Visa Number:
Status:
Are you eligible to work in the United States?*

YesNo
U.S. Military Service/Public Health:*

YesNo
Dates of Service:
(MM/DD/YYYY to MM/DD/YYYY)
Last Location:
Branch of Service:
Are you currently on active or reserve military duty?

YesNo

Other Graduate-Level Education:
Institution:
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Degree:
Attendance Dates:
(MM/YYYY to MM/YYYY)