Perfusionist Licensure

Attention Applicant

Pursuant to NRS 630.167, as part of the application process, you are required to submit to a criminal background investigation. Upon receipt of your completed application, your License Specialist will send you an authorization form, the appropriate fingerprint cards, and instructions. 

Forms

Perfusionist Application for Licensure
Use this link to apply online for licensure as a Perfusionist in the state of Nevada.
Application Checklist - Perfusionist Application
Form 1 - Perfusionist Application
Education Verification
Form 2 - Perfusionist Application
ABCP Certification
Form 3 - Perfusionist Application
Verification of State Licensure/Certification
Form 4 - Perfusionist Application
Malpractice Claim Verification
Form 5 - Perfusionist Application
Hospital Privileges Verification
Form A - Perfusionist Application
Release
Form B - Perfusionist Application
List of Malpractice Insurance Carriers
Form C - Perfusionist Application
Request for Licensure by Endorsement
Civil Applicant Waiver - Perfusionist Application
Responsibility Statement
Perfusionist Application for License Reinstatement 2021-2023
Use this form to apply for reinstatement of your license.
Notification of Practice Location
Notification of Supervising Perfusionist - For Temporary Perfusionist Applications ONLY

General Forms

Address Change Form
Name Change Form
License Verification Request Form
Replacement Wall Certificate Order Form
Petition for Review of Criminal History