2

3

4

5

6

7

8 Smaller than a 10 font

9

10

11

12 Smaller than 10 font

13

14

15 If you are one of the professions listed on this page YOU MUST SEND IN PROOF (a copy) OF YOUR license, registration or waiver:

16

17

18

Mail your application and all documents by or before August 17, 2012 to: Health Professions Education Foundation ATTN: MHLAP 400 R Street, Room 460 Sacramento, CA Frequently Asked Questions at: County contact List at: wwwhealthprofessions.ca.gov/mhlap Phone: (800) (916) Foundation Website at: 19