Please provide the below information to request a
Computer Based Exam:
Last Name:   First Name:   Middle Initial/Name:
Address:
Address:
City:   State:   Zip Code:
Cell or Home Phone:
Work Phone:
Gender:
Date of Birth:
Email Address:
Verify Email:
Exam Type:

·         If this is first time taking the above requested exam, a license application and $35.00 fee is required.
·         If this exam registration is to repeat the above requested exam, a $25.00 fee is required.  Please use the re-exam fee, billing invoice provided with your previous exam results to submit the fee.
·         If this is first time taking the above requested exam, attendance of all mandatory training requirements must be documented as met prior to taking the exam.  Please submit copies of attendance certificates immediately, or if attendance of course is scheduled, please provide schedule.
·         If above fee and training documents have not been submitted, a delay in processing this request will occur awaiting needed submittals.
·         The computer based exam provider (PSI) requires an exam administration fee of $69.00 to be paid when the exam scheduled with PSI, an instructional email from PSI will be provided.


Selecting the submit button obligates the above exam applicant to the above required licensing fees and training documentation.


Arkansas Department of Health
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