2910 East Madison Street

Seattle, WA  98112

Phone:  (206) 860-2410

Fax:  (206) 860-2411

Application Form

First Name ___________________________    Last Name ________________________________

Birthdate ___________________ Sex ____

Home Address ___________________________________________________________________

________________________________________________________________________________

Home Phone _________________________                  Cell Phone: _________________________

Graduate School ____________________________    Degree Obtained _____________________

Major Area of Study ______________________    Year Degree Obtained __________

Specialties _______________________________________________________________________

Years in Private Practice _____________________

Type of Professional License ____________________            WA Prof. License #___________________

Have you ever had your professional license revoked?   Yes_____    No_____

Have you ever had a legal or civil complaint filed against you?   Yes_____  No_____

              If yes, please explain? _______________________________________________________