Form L1f - California
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1MBC
PHOTOGRAPH
Use Only
Notice: All items in this application are mandatory. Failure to
Photograph
provide any of the requested information will delay the
processing of your application. The information provided will be
Affix a 2” X 2” Photo Here
used to determine your qualifications for licensing per Section
2080 of the California Business and Professions Code, which
Photograph
Photo Must Be Recent and
authorizes the collection of this information. The information on
Must Be of your Head and
your application may be transferred to other medical licensing
Shoulder Areas Only
authorities, the Federation of State Medical Boards, or other
governmental law enforcement agencies. You have the right to
Altered Photographs
review your application subject to the provisions of the
are NOT Acceptable
Information Practices Act. The Chief of the Licensing Program
is the custodian of records.
DECLARATION
Applicant
Name & DOB
The applicant
, _______________________________________________________________, ____________________,
Please print full name (First, Middle, Last)
Date of Birth (mm/dd/yyyy)
being first duly sworn upon his/her oath deposes and says: that I am the person herein named subscribing to
this application; that I have read the complete application, know the full content thereof, and declare under
penalty of perjury, that all of the information contained herein and evidence or other credentials submitted
herewith are true and correct; that I am the lawful holder of the degree of Doctor of Medicine as prescribed by
this application, that the same was procured in the regular course of instruction and examination, and that it,
together with all the credentials submitted, were procured without fraud or misrepresentation or any mistake of
which I am aware and that I am the lawful holder thereof. Further, I hereby authorize all hospitals, institutions
or organizations, my references, personal physicians, employers (past, present and future), or business and
professional associates (past, present, and future), and all government agencies (local, state, federal, or
foreign) to release to the Medical Board of California or its successors any information, files or records,
including medical records, educational records, and records of psychiatric treatment and treatment for drug,
alcohol and/or substance abuse or dependency, requested by that Board in connection with this application; or
any further or future investigation by that Board necessary to determine any medical competence, professional
conduct, or physical or mental ability to safely engage in the practice of medicine. I further authorize the
Medical Board of California or its successors to release, in any investigation or proceeding, to the
organizations, individuals or groups listed above any information which is material to this application or any
subsequent licensure.
I UNDERSTAND THAT ANY OMISSION, FALSIFICATION OR MISREPRESENTATION OF ANY ITEM OR
Applicant
RESPONSE ON THIS APPLICATION OR ANY ATTACHMENT HERETO IS A SUFFICIENT BASIS FOR
Signature
& Date
DENYING OR REVOKING A LICENSE.
SIGNATURE:
DATE:
__________________________________________
________________________
NOTARY SECTION
Applicant
Signature
SIGNATURE OF APPLICANT: __________________________________________________________
(DO NOT SIGN EXCEPT IN THE PRESENCE OF NOTARY – Please sign full name)
State of
_________________________
County of _________________________
Applicant
Name &
Notary Date
Subscribed and sworn to (or affirmed) before me on this ________ day of _________________, 20_____,
by, _________________________________________ proved to me on the basis of satisfactory evidence
(Print applicant’s name)
Notary
NOTARY SEAL
Signature
to be the person who appeared before me.
& Seal
_____________________________________
L1F
SIGNATURE OF NOTARY PUBLIC
07A-100 Revised 8/2013
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