States where you want to obtain a Medical License: |
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If you were directed by a company to apply through MedLicense.com - please enter the name of the company here: |
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Full Legal Name (on Identity Documents and Medical School Diploma): |
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Mailing Address: |
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Phone Number: |
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Email: |
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Date of Birth: |
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Place of Birth: |
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Social Security Number: |
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Degree Type (MD, DO, PA, NP, DDS, DMB, etc): |
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Medical School Name and Location: |
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Medical School Dates of Attendance & Graduation Date: |
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ECFMG Number and Issue Date: |
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Total number of Years of PGY (Internship/Residency/Fellowships) in the USA, Canada, or Puerto Rico: |
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States where you have been licensed Past and Present: |
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Board Certification: |
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Year First Certified and Re-Certified: |
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What License Examination did you Take? |
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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) |
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Height, Weight, Eye Color, Hair Color |
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Credit Card Number: |
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Credit Card Expiration Date: |
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Credit Card 3-4 digit Pin # (on Back of the Card - VISA, MC, or Discover - on Front for AMEX) |
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Name on the Credit Card: |
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Billing Address of the Credit Card: |
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Add Additional Services: |
Auto-License Renewal $170 (Per License Per Renewal Cycle) |
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