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Issuance Fee

Issuance Fee

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Thank you for choosing to pay for your service with the Board’s online payment option. 

Fields marked with an asterisk* are required and must be completed prior to clicking Pay Now.

A $3.00 Convenience Fee will be added to your total.

Customer Information

Facility Information

R4-33-211 Notice of appointment, within 30 days. If you will be the administrator of record at a facility right away, you can use the space below to provide the name, address and phone number of the facility you will be overseeing. Or, you can leave it blank and notify the Board later. You can use the printable address change form on our website to update contact information and facility information at any time.

Facility Address


Initial Certification Fee
Payment Detail