Form 3b - Verification Of Pre-1972 Medical Licensure In Another U.s. State Or Territory Page 2

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SECTION II : CERTIFICATION OF MEDICAL LICENSURE
INSTRUCTION TO LICENSING AUTHORITY:
Please complete this section including names and grades on all parts of the licensing
examination and return this form directly to the Office of the Professions at the address shown below. This form will not be accepted if returned
by the applicant or a third party.
1.
Name of Applicant: __________________________________________________________________________________________
2.
Medical License Number: _______________________________
Date of Licensure: ____________________________________
3.
On what basis was applicant licensed in your state or territory? ________________________________________________________
__________________________________________________________________________________________________________
YES
NO
4.
Is the licensee currently registered and in good standing?
Are charges pending against the licensee for professional misconduct, unprofessional conduct, incompetence
5.
YES
NO
or negligence or has the licensee ever been found guilty of such charges or surrendered a professional license?
If "Yes", explain _____________________________________________________________________________________________
6.
Please specify the state or national medical examinations successfully completed by the applicant:
__________________________________________________________________________________________________________
If the applicant was licensed in your state (territory) via a state (territory)-constructed examination, please complete the following (list
the exam subjects in chronological order):
Name of Examination and
Minimum
Date
Grade
List of Subject Areas
Passing Grade
I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the record of professional licensure of the individual
named on this form.
Signature: ___________________________________________________________________ Date: _____ / _____ / _____
Print name: _________________________________________________________________
Title: _______________________________________________________________________
(SEAL)
Agency: ____________________________________________________________________
Address: ____________________________________________________________________
____________________________________________________________________________
Telephone Number ___________________________ Fax: ___________________________
E-mail Address: ______________________________________________________________
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Return this form directly
Medicine Unit, 89 Washington Avenue, Albany, NY 12234-1000.
to:
FORM 3B, PAGE 2 OF 2
September 2002

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