Form 4 - Verification Of Professional Practice Of Medicine In Another Jurisdiction Page 2
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1
2SECTION II : VERIFICATION OF PROFESSIONAL PRACTICE
ENDORSER INSTRUCTIONS
1.
A physician licensed and in good standing in the jurisdiction where applicant is licensed is to complete the information below and have his/her
signature notarized by a Notary Public.
2.
This completed form must be sent directly by the affiant to the Office of the Professions at the address at the bottom of this form.
1
I know him/her to be of good moral character, and recommend him/her to the New York State
YES
NO
Education Department as entirely worthy to be licensed to practice medicine in the State of New York.
2
I have been personally acquainted with the applicant named in Section I for ____________________________ years.
3
I have first-hand knowledge that said applicant has ___________ years and ___________ months of satisfactory professional
experience following medical licensure and can attest to practice by the applicant for the following:
DATE
FROM
TO
PRACTICE LOCATION
Month/Year
Month/Year
SECTION III:
ENDORSER AFFIRMATION
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I understand that any
false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.
Signature of endorser: _____________________________________________________________________________ Date: ___________________
(Must be signed in the presence of a notary)
Print name as it appears on your license: _____________________________________________________ License number: ___________________
State: ___________________ Address: _________________________________________________________________________________________
Telephone: _________________________ Fax: _________________________ E-mail: ___________________________________________________
NOTARY CERTIFICATION OF IDENTIFICATION
(Certification by Notary Public is required.)
State of __________________________________ County of _______________________________________
I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this applicant by: (a)
comparing his/her signature made in my presence on this form with the signature on his/her identifying document. The statements on this document
are subscribed and sworn to before me by the endorser on this __________ day of ____________________, __________.
Notary Public signature ___________________________________________________________________
Notary ID number _____________________________
Expiration date __________ / __________ / ________
Month
Day
Year
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 4, PAGE 2 OF 2
September 2002
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