State Form 29495 - Application For License To Practice Medicine / Osteopathic Medicine In Indiana
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3Health Professions Bureau
APPLICATION FOR LICENSE TO PRACTICE MEDICINE /
402 W. Washington St., Room 041
OSTEOPATHIC MEDICINE IN INDIANA
Indianapolis, IN 46204
T elephone number: (317) 232-2960
State Form 29495 (R10 / 11-01)
Approved by State Board of Accounts, 2001
* Your Social Security number is being requested by this state agency in accordance with
IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.
Application fee
Date fee paid (month, day, year)
Permit fee
Receipt number
Date fee paid (month, day, year)
APPLICANT
Application number
Receipt number
Attach one (1) passport type quality
photograph of yourself taken within the
License number
Permit number
last eight weeks.
License issuance date (month, day, year)
Permit issuance date (month, day, year)
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Check one:
Name of applicant (last, first, middle, maiden)
Social Security number *
MD
DO
Address (number and street or Rural Route)
City, state, ZIP code
Birthdate (mo., day, yr.)
Birthplace
T elephone number (daytime)
(
)
E-mail address
TEMPORARY PERMIT INFORMATION
Do you desire a temporary permit?
Yes
No
DOCTOR OF MEDICINE / OSTEOPATHIC DEGREE GRANTED BY
Name of School
Location
Date of Graduation (Month, Day, Year)
EXAMINATION
Check appropriate box(es) indicating which examination or combination of examinations you have taken.
(Please review instruction sheet for address and telephone numbers on how scores may be obtained.)
FLEX EXAMINATION
STATE BOARD EXAMINATION
Examination taken in which state?
Component I
Component II
Other
NATIONAL BOARD OF MEDICAL EXAMINERS
LMCC EXAMINATION
Part I
Part II
Part III
NATIONAL BOARD OF OSTEOPATHIC MEDICAL EXAMINERS
USMLE EXAMINATION
Part I
Part II
Part III
Step I
Step II
Step III
Page 1
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