OASAS Account

OASAS Registration

First Name: *

MI:

Last Name: *

Credential/License Name (if applicable):

Credential/License Number (if applicable):

Your Street Address: *

City: *

ST: *

Zip Code: *

Your Email Address: *

Your Phone Number: *

Create a Password: *

Repeat Password: *

Last 4 digits of Your SSN: *

Your Birth Date (mo/dy/year): *

Are you currently Employed? *

Yes No

Is OASAS your current employer? *

Yes, I am employed by OASAS No, I have another employer

Full Name of Your Current Employer: *

Is your employer approved by OASAS to provide screening, assessment, and treatment services to impaired driving offenders? *

Yes No