Identification

You are applying for the Physician Assistant License

Thank you for your interest in applying for a license. As you complete your application for online submission, the agency and the Texas Medical Board, Texas Physician Assistant Board, and the Texas State Board of Acupuncture Examiners want to make you aware of a few facts regarding criminal conduct, convictions, and disciplinary actions in other states.

The mission of the boards is to protect and enhance the public's safety, health and welfare by establishing and maintaining standards of excellence used in regulating the practice of medicine and ensuring quality health care for the citizens of Texas through licensure, discipline and education. One way the boards protect the public is by issuing licenses to fully qualified, competent and ethical applicants.

During the licensing process you will be asked whether you have ever been investigated by any state, arrested, charged, convicted or pled guilty to a crime. An arrest, subsequent criminal conviction, placement on deferred adjudication/prosecution, or disciplinary action is not an automatic disqualification from licensure. Instead, the facts surrounding the criminal conduct and disciplinary action will be reviewed to determine whether you are fit for licensure. You should know that licensure is a privilege, not a right. One thing you must do to obtain the privilege is to be completely honest on your licensure application.

Be sure to list all relevant complaints, disciplinary actions, charges, or convictions in response to the licensure questions. Failure to disclose such events could constitute grounds alone for imposition of fines or placement of limitations on your license, or even the denial of your application, or revocation of your license. Avoid some of the common excuses heard from people who fail to disclose, such as:

• My attorney told me I didn't have to disclose the criminal conduct or disciplinary actions.
• I didn't think the prior conduct had anything to do with the profession.
• I didn't think the disciplinary action, arrest, charges, or conviction was still on my record.
• I didn't think it was subject to disclosure because I received a deferred sentence/judgment.

Remember, there is no excuse not to disclose relevant complaints, disciplinary actions, charges, or convictions. Even after licensure, you are still required to report to the appropriate Board about subsequent convictions and disciplinary actions in other states, as they must be reported on your physician profile.

The Boards query several criminal and national disciplinary databases. This allows the Boards to verify the truthfulness of your application and track subsequent criminal and disciplinary conduct after initial licensure. Keep in mind, you will not necessarily be denied a license or be subject to a licensure action if you have been disciplined, arrested, charged or convicted, but action will most likely be taken on your application or license if you fail to disclose it.

Full Disclosure: It is imperative that you honestly and fully answer all questions, regardless of whether you believe the information requested is relevant. If you are unsure of your response to a particular question, answer "Yes" and submit the appropriate form if required. Your responses on your application are evaluated as evidence of your candor and honesty. An honest "Yes" answer to a question on your application is not definitive as to the assessment of your present professional character and fitness, but a dishonest "No" answer is evidence of a lack of candor and honesty, which may be definitive on the character and fitness issue. Please be advised that a false response to any of these questions may be grounds for denial of licensure and reported to the appropriate data banks.

Jurisprudence Identification Acudetox Specialist Applicants may skip this question; the jurisprudence examination is not required for certification as an acudetox specialist. For JP first and last name, provide your name as it is listed on either your current driver license, issued by a state driver license bureau in the United States, or your current passport. We will furnish this information to the testing center that administers the jurisprudence exam (JP). Your name must match exactly when you present your identification at the testing center, or you will not be allowed to take the exam. JP First Name JP Last Name
Full Name as you wish it to appear on your receipt(required)
Your name, as entered in the next 4 fields, will be the name that appears on your license and on the web site verification page.
Applicant First Name(required)
Applicant Middle Name
Applicant Last Name(required)
Suffix	JUNIOR SENIOR II III IV V
Alternate Names
Email Address (xx@xx.xxx)
U.S. Social Security Number (###-##-#### or #########)(required)
Gender(required) Male Female
Country of Birth(required)	UNITED STATES AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO (BRAZZAVILLE) CONGO (KINSHASA) COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTH TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD MCDONALD ISLANDS HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA (PEOPLES REPUBLIC) KOREA (REPUBLIC OF) KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTH MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA ST PIERRE AND MIQUELON ST VINCENT GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA S GEORGIA AND S SANDWICH SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM US MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VATICAN CITY STATE VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE
If you were born in the United States, please select your state of birth.
US State of Birth	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Date of Birth (MM/DD/YYYY)(required)
Race(required)	White Black or African American American Indian or Alaska Native Asian Native Hawaiian/Pacific Islander Other
Are you of Hispanic Origin?(required) Yes No
If you are a Texas high school graduate, please select the county where your high school is located.
Texas High School County	ANDERSON ANDREWS ANGELINA ARANSAS ARCHER ARMSTRONG ATASCOSA AUSTIN BAILEY BANDERA BASTROP BAYLOR BEE BELL BEXAR BLANCO BORDEN BOSQUE BOWIE BRAZORIA BRAZOS BREWSTER BRISCOE BROOKS BROWN BURLESON BURNET CALDWELL CALHOUN CALLAHAN CAMERON CAMP CARSON CASS CASTRO CHAMBERS CHEROKEE CHILDRESS CLAY COCHRAN COKE COLEMAN COLLIN COLLINGSWORTH COLORADO COMAL COMANCHE CONCHO COOKE CORYELL COTTLE CRANE CROCKETT CROSBY CULBERSON DALLAM DALLAS DAWSON DEAF SMITH DELTA DENTON DEWITT DICKENS DIMMIT DONLEY DUVAL EASTLAND ECTOR EDWARDS ELLIS EL PASO ERATH FALLS FANNIN FAYETTE FISHER FLOYD FOARD FORT BEND FRANKLIN FREESTONE FRIO GAINES GALVESTON GARZA GILLESPIE GLASSCOCK GOLIAD GONZALES GRAY GRAYSON GREGG GRIMES GUADALUPE HALE HALL HAMILTON HANSFORD HARDEMAN HARDIN HARRIS HARRISON HARTLEY HASKELL HAYS HEMPHILL HENDERSON HIDALGO HILL HOCKLEY HOOD HOPKINS HOUSTON HOWARD HUDSPETH HUNT HUTCHINSON IRION JACK JACKSON JASPER JEFF DAVIS JEFFERSON JIM HOGG JIM WELLS JOHNSON JONES KARNES KAUFMAN KENDALL KENEDY KENT KERR KIMBLE KING KINNEY KLEBERG KNOX LAMAR LAMB LAMPASAS LASALLE LAVACA LEE LEON LIBERTY LIMESTONE LIPSCOMB LIVE OAK LLANO LOVING LUBBOCK LYNN MCCULLOCH MCLENNAN MCMULLEN MADISON MARION MARTIN MASON MATAGORDA MAVERICK MEDINA MENARD MIDLAND MILAM MILLS MITCHELL MONTAGUE MONTGOMERY MOORE MORRIS MOTLEY NACOGDOCHES NAVARRO NEWTON NOLAN NUECES OCHILTREE OLDHAM ORANGE PALO PINTO PANOLA PARKER PARMER PECOS POLK POTTER PRESIDIO RAINS RANDALL REAGAN REAL RED RIVER REEVES REFUGIO ROBERTS ROBERTSON ROCKWALL RUNNELS RUSK SABINE SAN AUGUSTINE SAN JACINTO SAN PATRICIO SAN SABA SCHLEICHER SCURRY SHACKELFORD SHELBY SHERMAN SMITH SOMERVELL STARR STEPHENS STERLING STONEWALL SUTTON SWISHER TARRANT TAYLOR TERRELL TERRY THROCKMORTON TITUS TOM GREEN TRAVIS TRINITY TYLER UPSHUR UPTON UVALDE VAL VERDE VAN ZANDT VICTORIA WALKER WALLER WARD WASHINGTON WEBB WHARTON WHEELER WICHITA WILBARGER WILLACY WILLIAMSON WILSON WINKLER WISE WOOD YOAKUM YOUNG ZAPATA ZAVALA
Physician Assistant Applicants Only All other applicants, please continue to the next section. Use this school code list to locate the code for your PA school. Copy your code from the list and paste it into your application below. If you are unable to locate your code, please use the code for an unassigned school, and be aware that this will delay the processing of your application. PA School Code Year of Graduation (YYYY) NCCPA Certification Number (Must be numeric. If pending, leave blank.) Are you currently on active duty in the U.S. Military? Yes No
Acupuncture Applicants Only All other applicants, please continue to the next section. Use this school code list to locate the code for your Acupuncture school. Copy your code from the list and paste it into your application below. If you are unable to locate your code, please use the code for an unassigned school, and be aware that this will delay the processing of your application. Acupuncture School Code Year of Graduation (YYYY) NCCAOM Certification Number
Acudetox Specialist Applicants Only Use this training program code list to locate the code for your Auricular Acupuncture Training Program. Copy your code from the list and paste it into your application below. If you are unable to locate your code, please use the code for an unassigned program, and be aware that this will delay the processing of your application. Auricular Acupuncture Training Program Code