Form 08-4215g - Alaska State Board Of Certified Direct-Entry Midwives Verification Of Licensure
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1
2ALASKA STATE BOARD OF CERTIFIED DIRECT-ENTRY MIDWIVES
VERIFICATION OF LICENSURE
This form is essential to the application you are filing with this board. The information requested below must be officially verified by the
licensing boards/agencies in all states of licensure. Please complete the information requested and forward it to the state(s) in which you
hold or have held a license to practice. You are advised to check with that state before forwarding this form to determine if there
are additional requirements to be met before the information will be released, i.e., verification fee. (Copy this form as needed)
PART I
TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):
Last Name
First Name
Middle Name
Maiden Name
Mailing Address
City
State
ZIP Code
Date of Birth
License No.
I hereby request and authorize the State of
to provide any and all pertinent information requested
in this form to the Board of Certified Direct-Entry Midwives in the State of Alaska to complete an application filed with that agency.
Signature
Date Signed
PART II
NOT TO BE COMPLETED BY THE APPLICANT
The above applicant is applying for licensure in Alaska. Please complete the following and return directly to the Alaska State Board
of Certified Direct-Entry Midwives.
State of
Name of Licensee
License No.
Original Issue Date
YES
NO
By reciprocity/endorsement/credentials
By examination:
State Board Examination
NARM Examination
License is
current
Lapsed
Expiration Date
Expiration Date
If the applicant's license has lapsed or expired, please explain why (e.g., failure to pay licensing renewal fees, etc.)
CLINICAL EXPERIENCE REQUIREMENT
Does your state require for licensure:
YES
NO
1.
An apprenticeship?.............................................................................................................................................
How long?
2.
Supervised clinical experience including:
a. at least 100 prenatal visits? .....................................................................................................................
b. at least 10 labor and delivery observations (preceding any primary responsibility)?...............................
c. at least 20 assisted labor managements (preceding any primary responsibility)?...................................
d. primary responsibility for at least 30 labor and deliveries of newborn and placenta?..............................
e. at least 30 newborn examinations? .........................................................................................................
f. at least 30 postpartum examinations of mother? ......................................................................................
08-4215g (Rev. 11/99)
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