Form 08-4022 - Application For Resident Permit - 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
Receipt No
Amount
Application for RESIDENT 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
SOCIAL SECURITY NUMBER
DATE OF BIRTH
Month:
Day:
Year:
-
-
PART II
RESIDENT ROTATION ASSIGNMENT
Identify the Alaska facility where you
will be serving your rotation.
Name:
Location:
Date Scheduled:
Mo
Day
Yr
PART III
EDUCATION INFORMATION -
Medical School Education
Name of Institution
Location
Date Grad.
Postgraduate Training Programs
Date
Compltd
Name of Institutions
From/To
Yes/No
Name
Fr:
1st Yr
Address
To:
Name
Fr:
2nd Yr
Address
To:
Name
Fr:
3rd Yr
Address
To:
Name
Fr:
4th Yr
Address
To:
SPECIALTY_______________________________________________________________________
08-4022 (Rev 09/2000)
Page 1 of 4
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