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If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location,

date and diposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement.

Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application.

1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held?

Yes

2. Have you ever been denied a license, certificate, registration or permit to practice medicine, osteopathic medicine or any

Yes

regulated health occupation in any state (including Indiana) or country?

3. Are you now being, or have you ever been, treated for a drug abuse or alcohol problem?

Yes

4. Have you ever been charged with drug addiction?

5. Have you ever been convicted of, plead guilty or nolo contendere to:

Yes

A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled

substances or drug addiction?

B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.)

Yes

6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or

Yes

privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations?

7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health

Yes

care facility in which you have trained, held staff membership or privileges or acted as a consultant?

8. Have you ever had a malpractice judgment against you or settled any malpractice action?

Yes

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.

Signature of applicant

Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorized, request and direct any person, firm, officer, corporation, association, organization or institution to release to the

Health Professions Bureau of Indiana any files, documents, records or other information pertaining to the undersigned requested by

the Bureau, or any of its authorized representatives in connection with processing my application for medical licensure.

I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any

liability with regard to such inspection or furnishing of any such information.

I further authorize the Health Professions Bureau of Indiana to disclose to the aforementioned organizations, persons, and institutions

any information which is material to my application, and I hereby specifically release the Bureau and Board from any and all liability in

connection with such disclosure.

A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.

Date signed (month, day, year)

Signature of applicant

Page 3

State Form 29495 - Application For License To Practice Medicine / Osteopathic Medicine In Indiana Page 3

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