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Application for  Licensure

Credit Card First Name:  
Credit Card Last Name:
 Billing Address:
City:  
State:
Zip:
Country:

Phone Number:


Credit Card Information


Card Number:
Exp. Date:

Personal Information

Type of License     
MD 
DO
OD 
NP
PA
RN
LPN
Other
Full Legal Name
Maiden Name
Name on Birth Certificate
Explanation of Change (If any)
Other names under which material may be submitted - Include Maiden Name - Do not use nicknames
US Social Security Number
Mailing Address 

 

Employer's Name

Work Address

Which State or States do you want us to set up for you?

Contact Phone Number

Fax Number

Email Address

Work Phone Number

Date of Birth (MM/DD/YY)
Place of Birth
  Male Female USA Citizen? Yes No
   
List the names and locations of all colleges or universities attended where pre-professional, post-secondary instruction was received:
High School  
City & State
Year of Graduation
Pre-Med College/University Name
City & State
Country
Zip/Postal Code
Attendance (MM/YY-MM/YY) /-/
Degree None   BA BS MA    MS   Other  

(If other then: )

 

   
Pre-Med College/University  # 2
Address
City & State
Country
Zip/Postal Code
Attendance (MM/YY-MM/YY) /-/
Degree None   BA BS MA    MS   Other  

(If other then: )

 

Pre-Med College/University Name # 3
Address
City & State
Country
Zip/Postal Code
Attendance (MM/YY-MM/YY) /-/
Degree None   BA BS MA    MS   Other  

(If other then: )

 

 

Complete Name of Medical School (If Physician): 

   (Do Not Abbreviate)

Address of Medical School:                  

City, State, Country, and Zip Code:                     

Dates of Attendance: (MM/YY-MM/YY)

/-/

Exact Date of Graduation: (MM/DD/YY)

//

Degree: None  MD DO MD/PhD  MBBS

Did you ever take a leave(s) of absence or break(s) from your medical education?

Yes No

Where you ever placed on probation? Yes No
Were you ever disciplined or placed under investigation? Yes No
Were any negative reports ever filed against you? Yes No
Were any limitations or special requirements imposed on you because of academic, incompetence, disciplinary problems or for any other reason? Yes No
Please explain any "Yes" responses from above:

Did you attend a Fifth Pathway program?

Yes No

Did you complete any clinical clerkship in a country other than where your medical school is located? Yes No

Examinations

Examination Last  Attempt # of Attempts Result
State Board Exam State:

Pass Fail

FLEX Pre-1985 State: Pass Fail
FLEX Comp. 1 State: Pass Fail
FLEX Comp. 2 State: Pass Fail
LMCC State: Pass Fail
NBME-Part I State: Pass Fail
NBME-Part II State: Pass Fail
NBME-Part III State: Pass Fail
SPEX State: Pass Fail
NBOME State: Pass Fail
USMLE Number      
USMLE Step 1 State: Pass Fail
USMLE Step 2 State: Pass Fail
USMLE Step 3 State: Pass Fail
Have you ever been licensed to practice medicine in any state, territory, province, country, or U.S. federal jurisdiction?

Yes    No

If yes then list each below:

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

State / Country

License Number

Date Issued   // 

Expiration Date // 

Status of License

 
Do you hold any other professional license in any state, territory, province, country, or U.S. Federal Jurisdiction?                     Yes          No

If Yes:

Profession  License Number

Jurisdiction

Has this license ever been revoked, or subject to discipline?          Yes          No

Postgraduate Medical Education (Internship/Residency/Fellowship)

 

Complete Name of Hospital where training was conducted.
Complete Name of Affiliated University
Director's Name & Department
City
State/Province, & Country
Type of Training (check all that apply)

Internship Residency Fellowship Research

Name of Program/Training
From - To (MM/YY-MM/YY)

/-/

Successfully Completed?

Yes No In Progress

Did you ever take a leave(s) of absence or break(s) from your medical education?

Yes No

Were you ever placed on probation? Yes No
Were you ever disciplined or placed under investigation? Yes No
Were any negative reports ever filed against you? Yes No
Were any limitations or special requirements imposed on you because of academic, incompetence, disciplinary problems, or for any other reason? Yes No
Please explain any "Yes" responses from above:

Postgraduate Medical Education # 2

 

Complete Name of Hospital where training was conducted.
Complete Name of Affiliated University
Director's Name & Department
City
State/Province, & Country
Type of Training (check all that apply)

Internship Residency Fellowship Research

Name of Program/Training
From - To (MM/YY-MM/YY)

/-/

Successfully Completed?

Yes No In Progress

Did you ever take a leave(s) of absence or break(s) from your medical education?

Yes No

Were you ever placed on probation? Yes No
Were you ever disciplined or placed under investigation? Yes No
Were any negative reports ever filed against you? Yes No
Were any limitations or special requirements imposed on you because of academic, incompetence, disciplinary problems, or for any other reason? Yes No
Please explain any "Yes" responses from above:

 

Postgraduate Medical Education #3

 

Complete Name of Hospital where training was conducted.
Complete Name of Affiliated University
Director's Name & Department
City
State/Province, & Country
Type of Training (check all that apply)

Internship Residency Fellowship Research

Name of Program/Training
From - To (MM/YY-MM/YY)

/-/

Successfully Completed?

Yes No In Progress

Did you ever take a leave(s) of absence or break(s) from your medical education?

Yes No

Were you ever placed on probation? Yes No
Were you ever disciplined or placed under investigation? Yes No
Were any negative reports ever filed against you? Yes No
Were any limitations or special requirements imposed on you because of academic, incompetence, disciplinary problems, or for any other reason? Yes No
Please explain any "Yes" responses from above:

Applicant Questionnaire

Have you served in the US Armed Forces?

Yes No

If Yes, please provide Rank & Branch
Are you required to pay Child Support?

Yes No

Have you ever withdrawn from, or been suspended, dismissed or expelled from a medical school or postgraduate training program OR have you ever taken leave of absence from such a school or program? 

Yes No

Have you ever been charged with, or been found to have committed, unprofessional conduct, professional incompetence, gross negligence, or repeated negligent acts or malpractice by any medical licensing board, other agency, or hospital? Yes No
Has any disciplinary action ever been filed or taken, including but not limited to, informal or confidential discipline, consent orders, or letters of warning, regarding the healing arts license which you now hold or have ever held? Yes No
Is any such action as described above pending? Yes No
Have you ever been denied a license, permission to practice medicine or any other healing arts in this or any other State, or voluntarily surrendered your narcotic (controlled substance) permit (state or federal) to any licensing board or any other agency, or is any such action pending? Yes No
Have you ever had staff privileges in a hospital denied, suspended, limited, revoked, or not renewed for medical disciplinary cause, or resigned from a medical staff in lieu of disciplinary or administrative action, or is any such action pending? Yes No
Do you have any condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? Yes No
Have you ever been convicted of, or pled nolo contendere to, ANY violation  of any local, state, or federal law of any state, territory, country, or U.S. federal jurisdiction? Yes No
Is there any criminal action related to the above pending? Yes No
Have you ever been arrested? Yes No
have you ever been denied the privilege of taking an examination given by any licensing Board or agency? Yes No
Has any licensing Board or agency ever denied you a certificate or a license? Yes No
Has any licensing Board or agency ever refused you renewal of a certificate or a license? Yes No
Have you ever been denied a DEA registration number? Yes No
Have you ever been issued a restricted DEA registration? Yes No
Are you currently registered with the DEA? Yes No
If you are registered with the DEA, provide the number and state of issue:  

 

Have you ever had any malpractice suits filed against you? Yes No
Have you ever been denied membership in or in any way sanctioned by any medical or osteopathic association, society, or specialty society? Yes No
Have you ever resigned from a hospital staff position or training program after a complaint or peer review action has been initiated against you? Yes No
Have you ever voluntarily surrendered a medical license? Yes No
Have you ever voluntarily surrendered a controlled substance registration? Yes No
Have you ever voluntarily surrendered a DEA registration? Yes No
To you knowledge, are you the subject of an investigation by any licensing Board or agency as of the date of this application? Yes No
Do you have any applications for licensure pending before any other licensing Board or agency? Yes No
Have you ever had any restrictions as a Medicaid or Medicare provider? Yes No
Have you ever defaulted on a state or federally funded and/or guaranteed school loan? Yes No
Have you ever defaulted on child support payments? Yes No
 
ECFMG Number

Date Issued (MM/DD/YY)

Physical Description
Height Feet Inches Weight
Race  Eye Color
Hair Color   
Physical Marks

Yes No

 

If yes then describe them below:

 

Specialty Certification

Specialty

Board Certified

Yes  No      If no:  

Are you qualified to sit for the examination? Yes  No  

Board Name

Initial Certification Date

Date of Most Recent Certification

Date Qualified

Qualification Expires

Specialty or Subspecialty

Board Certified

Yes  No      If no:  

Are you qualified to sit for the examination? Yes  No  

Board Name

Initial Certification Date

Date of Most Recent Certification

Date Qualified

Qualification Expires

(Sub) Specialty

Board Certified

Yes  No      If no:  

Are you qualified to sit for the examination? Yes  No  

Board Name

Initial Certification Date

Date of Most Recent Certification

Date Qualified

Qualification Expires

Reference # 1

Name                             MD DO
Mailing Address
Phone Number                Fax Number

Reference # 2

Name                             MD DO
Mailing Address
Phone Number                Fax Number

Reference # 3

Name                             MD DO
Mailing Address
Phone Number                Fax Number
Name of Future Supervising Physician #1 (if PA, NP, or RN)

Name of Future Supervising Physician #2 (if PA, NP, or RN)

 

USA and International Graduates - Hospital Privileges

 

Hospital

City, State

Name of Director

Dates of Privileges

   
Hospital

City, State

Name of Director

Dates of Privileges

   
Hospital

City, State

Dates of Privileges

Name of Director

   
Hospital

City, State

Dates of Privileges

Name of Director

How did you hear about us?  

Would you like to add DEA Registration Services for $60.00? Yes  No 

Agree to terms of release

 

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