Imc Form 100 - Application For Appointment As Qualified Medical Evaluator - California Department Of Industrial Relations

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APPLICATION FOR APPOINTMENT AS QUALIFIED MEDICAL EVALUATOR
For the Department of Industrial Relations
FOR IMC USE ONLY
Industrial Medical Council
QME NO.:
P. O. Box 8888
INPUT DATE:
San Francisco, CA 94128-8888
INPUT BY:
BLOCK 1
(FOR ALL APPLICANTS)
PLEASE TYPE OR PRINT LEGIBLY
Please list your primary location. Additional locations may be added when your fee assessment is paid. You will be billed shortly
after passing the QME test.
LAST NAME
FIRST NAME
MI
JR/SR
BUSINESS ADDRESS WHERE QME EVALUATIONS WILL TAKE PLACE
(DO NOT USE P. O. BOX)
CITY
ZIP
+
4
MAILING ADDRESS FOR CORRESPONDENCE, IF DIFFERENT
CITY
ZIP
+
4
(AREA CODE) PHONE NO.
(MM/YY)
YEAR ENTERED
CAL. PROFESSIONAL
EXPIRATION
LICENSE NUMBER
PRACTICE
PROCEED TO BLOCK 2
Must be fully completed before proceeding.
BLOCK 2 (FOR ALL APPLICANTS) IMPORTANT: BLOCK 2
PROFESSIONAL EDUCATION {INDICATE DEGREE OBTAINED (e.g. MD, DC, DO, Ph.D, Psy.D, Ed.D, etc.)}
COLLEGE/UNIVERSITY/MEDICAL SCHOOL/TRAINING
If MD or DO, COMPLETE BLOCKS 3,6,7,8,9,10
If DC, COMPLETE BLOCKS 4,7,8,9,10
If Ph.D, Psy.D or Ed.D, COMPLETE BLOCKS
CITY
STATE
DATE OF DEGREE
DEGREE
5,7,8,9,10
Other Degrees, COMPLETE BLOCKS 7,8,9,10
BLOCK 3
(FOR MDs AND DOs ONLY)
POSTGRADUATE TRAINING/EDUCATION:
NOTE:IF TRAINING WAS RECEIVED FROM A FACILITY/HOSPITAL OUTSIDE THE USA, PLEASE INDICATE BOTH CITY AND
COUNTRY IN LOCATION BOX (DO NOT ENTER “SEE RESUME”)
Year
Year
PGY 1 or INTERNSHIP:
Hospital/Facility
Location (City/State)
Type
From
To
RESIDENCY: Hospital/Facility
Location (City/State)
Type
From
To
RESIDENCY: Hospital/Facility
Location (City/State)
Type
From
To
RESIDENCY: Hospital/Facility
Location (City/State)
Type
From
To
FELLOWSHIP: Hospital/Facility
Location (City/State)
Type
From
To
IMPORTANT: IF APPLICANT IS BOARD CERTIFIED, PLEASE PROVIDE COPY OF BOARD CERTIFICATE(S).
.
OTHERWISE, PLEASE PROVIDE COPY OF CERTIFICATE(S) OF COMPLETION OF POSTGRADUATE TRAINING
PROCEED TO BLOCK 6
IMC FORM 100 (Rev. 12.00)

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