State Medical Licensing Order Form 

To begin the process, please enter your information below:  
States where you want to obtain a Medical License:
If you were directed by a company to apply through - please enter the name of the company here:
Full Legal Name (on Identity Documents and Medical School Diploma):
Mailing Address:
Phone Number:
Date of Birth:
Place of Birth:
Social Security Number:
Degree Type (MD, DO, PA, NP, DDS, DMB, etc):
Medical School Name and Location:
Medical School Dates of Attendance & Graduation Date:
ECFMG Number and Issue Date:
Total number of Years of PGY (Internship/Residency/Fellowships)  in the USA, Canada, or Puerto Rico:
States where you have been licensed Past and Present:
Board Certification:
Year First Certified and Re-Certified:
What License Examination did you Take?
Did you take more than 3 attempts on any Step of the Examination?  No    Yes
Did you take more than 7 years to pass the Examination Sequence?  No    Yes
Have you had any malpractice claims?  No    Yes
Please provide any information about potential negative information: (i.e. Probations, Leave of Absences, Board Actions, Probations, Arrests, Disciplinary Actions, Suspensions)
Height, Weight, Eye Color, Hair Color
Credit Card Number:
Credit Card Expiration Date:
Credit Card 3-4 digit Pin # (on Back of the Card - VISA, MC, or Discover - on Front for AMEX)
Name on the Credit Card:
Billing Address of the Credit Card:
Add Additional Services:   Auto-License Renewal $170 (Per License Per Renewal Cycle)

Hit Submit to Complete your Order