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 establish 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 to the best of your knowledge. 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.

If you choose to submit your application in paper form please choose the Paper form option below. Complete the application, print and then fax (904.339.9255) 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
20 Renn Lane
Palm Coast, FL 32164

If you have any questions regarding our online form or our paper form please contact us at 1.850.453.3608.

Online Form	Click here to fill out the physician application online or if you have already started the online application, click here to log in.
Physician Paper Form	Click here to download and print the physician application.
Nurse Paper Form	Click here to download and print the nurse application.
Note: Nurse Application is available only in download and print version or call us at (386) 437-8300 for a quote!