Contact us at (888) 551-2140

Order Form

Every effort has been made to streamline the medical licensing process for you. In order for us to provide you with the best service available, please follow these instructions:

1. Complete the order form below (all fields required)
2. Upload, email, mail, or fax a current CV to 801-512-2001

* This online order form works best with updated versions of all internet browsers. If you have difficulty using the online form, either update your browser or download a PDF version of the order form.

Step 1 - Physician Info

Name

Birthdate Birthplace

Degree

Specialty

In which state(s) are you interested?*
List states out with commas, such as "UT, AZ, CO"

Information on malpractice / disciplinary actions

Step 2 - Contact Info

Address

City State
Zip Country
Business Phone Home Phone

Email

How did you hear about us?

Step 3 - File Attachment

Upload your current CV and any supporting documentation that we will need to process your order. (3MB Limit)

Step 4 - Billing Info

Credit Card Number Type of Credit Card
Expiration Month Expiration Year

Full Service Licensing
For more information, please refer to our services page.

Full Service Credentialing
For more information, please refer to our services page.

Licensing Maintenance Service
For more information, please refer to our services page.

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