Form 08-4022 - Alaska State Medical Board
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1ALASKA STATE MEDICAL BOARD
MED
Department of Community and Economic Development
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
VERIFICATION OF GOOD STANDING
from
RESIDENCY TRAINING PROGRAM
Instructions to the Resident Applicant:
Complete Parts I, II, and III below. Type or print legibly. Submit the form to your residency
program director for signature
PART I
RESIDENT APPLICANT
Name (Last, First, Middle)
Date of Birth :
MD
DO
PART II
RESIDENCY PROGRAM
Name of Program
Address
City, State, Zip
Program Telephone
PART III
ROTATION AUTHORIZED FOR
Name of Alaska Facility, Hospital, Clinic
Location
Dates of Rotation:
From:
To:
(Applicant: Do No Write Below This Line. Do Not Detach.)
Instructions to Program Director:
Please complete Part IV below. Mail this form to the board at the letterhead
address.
PART IV
CERTIFICATION OF GOOD STANDING
I HEREBY CERTIFY that the resident physician named above is a resident in good standing at the residency
program shown above. There have been no disciplinary sanctions against this resident during his/her training in
this program. This physician will be serving a portion of his/her clinical training at the Alaska institution named
above. This program is approved by the Accreditation Council on Graduate Medical Education of the American
Medical Association or the Royal College of Physicians and Surgeons of Canada.
_______________________________________________
___________________________________
Signature, Physician Program Director
Printed Name
___________________________________
Date
08-4022 c (Rev 09/2000)
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