Form 08-4215g - Alaska State Board Of Certified Direct-Entry Midwives Verification Of Licensure Page 2

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Has the applicant's license ever been suspended or revoked?
If so, for what reason?
Has the applicant been subject to any other disciplinary action(s) (e.g., letter of warning, stipulation)? Please describe.
Please provide any information you believe relevant to the applicant's qualifications and fitness to practice midwifery:
General Comments:
Signed:
Printed Name:
Title:
SEAL
State Board:
Date:
Please return this form directly to:
Department of Community and
Economic Development
Division of Occupational Licensing
Alaska Board of Certified Direct-Entry Midwives
P.O. Box 110806
Juneau, AK 99811-0806
08-4215g (Rev. 11/99)

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