Form 08-4021 - Application For Locum Tenens Permit Form - 2000
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4ALASKA STATE MEDICAL BOARD
MED
Department of Community and Economic Development
For Office Use Only
Division of Occupational Licensing
(333 Willoughby Avenue - Ninth Floor)
Post Office Box 110806, Juneau Alaska 99811-0806
(907) 465-2541
E-Mail:
license@dced.state.ak.us
Application for
Receipt No
Amount
LOCUM TENENS PERMIT
PART I
PERSONAL INFORMATION
(Please type or print legibly.)
NAME--Last:
First:
Middle:
MD
DO
ADDRESS
CITY, STATE, ZIP
E-MAIL ADDRESS
WORK PHONE
HOME PHONE
:
/
:
/
Area Code
Area Code
DATE OF BIRTH
SOCIAL SECURITY NUMBER
Month:
Day:
Year:
-
-
PART II
LOCUM TENENS ASSIGNMENT
Identify the Alaska physician for whom you
will be substituting.
Name of AK Physician
Location
Start Date of Assignment:
PART III
EDUCATION INFORMATION
Medical School
Location
Year Graduated
Postgraduate Training Programs
Date
Completed
Name of Institutions
From/To
Yes/No
Name
From:
1st Year
Address
Specialty
To:
Name
From:
2nd Year
Address
Specialty
To:
Name
From:
3rd Year
Address
Specialty
To:
Name
From:
4th Year
Address
Specialty
To:
Board Certified:
Yes
No
What Specialty:________________________ Subspecialty______________________
Year of Certification:________
Current:
Yes
No
08-4021 (Rev 09/2000)
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