Submit New Application

Challenge Candidate Application Form 1101 Application

You must attach an image of your embossed, wet-ink signed CDPH 932 Form received from CDPH or your completed 283B form from your training program when you complete this form.

Legal First Name

Middle

Legal Last Name

Birthdate

Phone

Federal ID Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)

Gender

Male Female Other

Address

City

State

Zipcode

CDPH 932 Form or 283B Form

CDPH 932 Form or 283B Form You must attach an image of your embossed, wet-ink signed CDPH 932 Form received from CDPH when you complete this form.

Affidavit

I have attached an image of my embossed, wet-ink signed CDPH 932 Form received from CDPH or my completed 283B form from my training program.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.