Texas.gov Original Licenses Application

Process…

You are applying for the Perfusionist Provisional License

Renewing Current License?(required)

Are you renewing a current license that you hold with the Department of State Health Services?

Yes
No

Full name of individual completing online application(required)

Applicant Last Name(required)

Applicant First Name(required)

Middle Name

Suffix

Name on Transcript if different from applicant name

Social Security Number (###-##-####)(required)

Date of Birth (MM/DD/YYYY)(required)

Driver License Number(required)

State(required)

Applicant Email Address (abc@abc.com)

Business Telephone Number (###-###-####)(required)

Fax Number

Current Employment

Current Employer Name(required)
Current Employer Address(required)
City(required)
State(required)
Zip(##### or #####-####)(required)
Employer Phone (###-###-####)(required)
Start Date of Employment (MM/DD/YYYY)(required)