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Application for Licensure by Endorsement

-Licensure Type

I am applying for licensure as a:

-Biographical Information

example: 10/10/1990 Make sure to include the dashes
If you do not have a U.S. Social Security Number do not
continue with this application: Call (701) 328-9780
.
In compliance with the Federal Privacy Act of 1974, the disclosure of the individual's
social security number on this form is mandatory pursuant to North Dakota Century
Code 43-50-02. The individual's social security number is used for identification purposes.

-Contact Information

Use numbers or letters only, no punctuation (periods, commas, etc.) or other special characters.

If outside of the United States include city, province, country, etc. here
Choose Out of State if you reside outside of North Dakota. For countries outside of the United States, choose Out of Country.
MAKE SURE YOUR STATE IS CORRECT. (When using your mouse scrolling wheel you may have inadvertently changed it while trying to scroll down the page.)
example: 123-456-7890
example: mail@domain.com
example: mail@domain.com