Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Certification / Practice Information
List License and/or Certification Number(s) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Practice Specialty {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Institution / Business Where Practicing (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Website URL (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Examination*
You must check the box below to register for the examination.
I attest that I have been approved in writing (or by email) by the State of Oregon HLO to take this examination, and have met all of the HLO's requirements. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Comments or Questions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }