Choose one of the two options listed below. If you choose the Online form option you will be directed to a client login page. There you will create an account with a login name and password for your application access. You may return to your application as many times as needed in order to complete the application. Once your application is submitted you may not make any further corrections online, you may however contact us directly with any further information. Payment for you online applications may only be made in the form of a credit card.

To fill out the physician application online click below.
Online Form

Or if you have already started the online application,
click Login to log in and complete your form.

If you choose to submit your application in paper form please choose the Paper form option below. Complete the application, print and then fax (866.437.8771) or mail the application to our office. Payment is accepted in the form of credit card, check, or money order for all paper form applications submitted.

When paying with a check or money order please mail it to:
Nationwide Medical Licensing, LLC
705 Carousel St. SE.
Palm Bay, FL 32909

To download and print a paper application click below.
Physician Paper Form
Nurse Paper Form

Note: Nurse Application is available only in download and print version
or call us at 321.956.6982 for a quote!

If you have any questions please contact us at:
321.956.6982.