Form 08-4022 - Application For Resident Permit

PART IV

PROFESSIONAL HISTORY

Please list all states, territories, provinces of

Canada, or other countries in which you have EVER been licensed as any health care

professional (indicate as what profession; RN, PA, DDS, etc.):

________________

_______________

________________

_______________

________________

PART V

DISCIPLINARY HISTORY

If you resp ond “Yes” to any question, please attach

a detailed explanation along with copies of any

supporting documents available.

Have you ever had a license to practice medicine disciplined (except for late medical records)

including been placed on probation, reprimanded, censured, suspended, revoked, or otherwise

disciplined by (if yes, check appropriate organization):

___ any state medical board or other professional licensing authority?

Yes

___ any medical school or medical training program?

___ any military authority?

___ any health care organization (hospital, nursing home, clinic, health maintenance

organization, etc.)

Have you ever been charged with or convicted of (including suspended imposition of sentence)

Yes

a class A or unclassified felony or a crime in another jurisdiction with elements similar to a

class A or unclassified felony in this jurisdiction?

Have you ever been charged with or convicted of (including suspended imposition of sentence)

a class B or class C felony or a crime in this, or another jurisdiction with similar elements to this

Yes

jurisdiction, if the felony or other crime is substantially related to the qualifications, functions, or

duties of an individual licensed to practice medicine?

Have you ever voluntarily agreed to limitations or restrictions placed on your license, or

Yes

voluntarily surrendered your license to practice medicine in any licensing jurisdiction?

Have you ever voluntarily withdrawn or been asked to withdraw your application for a license to

Yes

practice medicine in any licensing jurisdiction?

Have you ever been charged with or convicted of a violation of a state law, regulation, or

Yes

statute, a federal law of the United States, or a law of any other country, excluding minor traffic

violations?

Yes

Are you currently the subject of any criminal investigation in any jurisdiction?

Are you currently the subject of an investigation by any medical licensing authority in any

Yes

jurisdiction?

Yes

Have you ever been denied a license to practice medicine by any licensing jurisdiction?

08-4022 (Rev 09/2000)

Page 2 of 4

Form 08-4022 - Application For Resident Permit - 2000 Page 2

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