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Applicant Information


First Name:	Middle Name:	Last Name:	Suffix
Date of Birth:	Gender:	Place of Birth:	U.S. Citizen:
SSN:	Current Certifications:	Highest Degree:	Please specify other degree:
Name to Appear on License/Registration:	Birth Name (if applicable):	Previous Names or Aliases:
Password

Password

Please input and confirm your password. You'll use this password to log back into your saved application and, in the future, when you need to log into NDSBPE forms.

Passwords must be at least 8 characters in length and include at least one:

uppercase letter (A-Z)
lowercase letter (a-z)
number (0-9)
special character (! @ # $ % ^ & * ( ) = - [ ] ' ; , . / { } | " : ?)


Password:	Confirm Password:

Contact Information

NDCC 43-32-16 requires a residential and business address be on file with the Board.


Business Email:	Business Phone:	Extension:
Personal Email:	Home or Cell Phone:
Business Address

Business Address


Name:
Street Address:
City:	State:	Zip Code:

Home Address


Street Address:
City:	State:	Zip Code:

Contact Preferences


Preferred Mailing Address:	Business	Home
Preferred Email Address:	Business	Personal