Texas Standardized Credentialing Application …

Texas Standardized Credentialing Application ( please type or print)LHL234 02 Texas Department of Insurance1of 12 Section I Individual InformationTYPE OF PROFESSIONALLAST NAMEFIRSTMIDDLE(JR., SR., ETC.)MAIDEN NAMEYEARS ASSOCIATED(YYYY YYYY)OTHER NAMEYEARS ASSOCIATED(YYYY YYYY)HOME MAILING ADDRESSCITYSTATE COUNTRYPOSTAL CODEHOME PHONE NUMBERSOCIAL SECURITY NUMBERF emaleMaleCORRESPONDENCEADDRESSCITYSTATE COUNTRYPOSTAL CODEPHONE NUMBERFAX NUMBERE-MAILDATE OF BIRTH(MM DD YYYY)PLACE OF BIRTHCITIZENSHIPIF NOT AMERICAN CITIZEN, VISA NUMBER& STATUSARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?Ye sN SERVICE PUBLIC HEALTHDATES OF SERVICE(MM DD YYYY)TO(MM DD YYYY)LAST LOCATIONYe sN oBRANCH OF SERVICEARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?Ye sN oEducationPROFESSIONAL DEGREE(MEDICAL, DENTAL, CHIROPRACTIC, ETC.)Issuing Institution:ADDRESSCITYSTATE COUNTRYPOSTAL CODEDEGREEATTENDANCE DATES(MM YYYY TO MM YYYY) please check this box and complete and submit Attachment A if you received other professional EDUCATIONSPECIALTYI nternshipResidencyFellowshipTeaching AppointmentINSTITUTIONADDRESSCITYSTATE COUNTRYPOSTAL CODEATTENDANCE DATES(MM YYYY TO MM YYYY)Program successfully completedPROGRAM DIRECTORCURRENT PROGRAM DIRECTOR(IF KNOWN)POST-GRADUATE EDUCATIONSPECIALTYI nternshipResidencyFellowshipTeaching AppointmentINSTITUTIONADDRESSCITYSTATE COUNTRYPOSTAL CODEE ducation continuedPOST-GRADUATE EDUCATIONATTENDANCE DATES(MM YYYY TO MM YYYY)Program succes

Texas Standardized Credentialing Application (Please type or print) LHL234 Eff.08⁄02 Texas Department of Insurance 1 of 12 Section I–Individual Information TYPE OF PROFESSIONAL LAST NAME FIRST MIDDLE (JR., SR., ETC.)

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