Form 08-4022 B - Verification Of Medical School Education Resident Application
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1ALASKA STATE MEDICAL BOARD
MED
Department of Community and Economic Development
Division of Occupational Licensing
For Office Use Only
(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
MEDICAL SCHOOL EDUCATION
RESIDENT APPLICATION
Instructions to the Resident Applicant:
Applicant to complete “Part I - Identifying Information” portion of form.
Type or print legibly. Mail to your medical school.
PART I
Identifying Information
Name of Graduate Physician (Last, First, Middle)
Maiden Name or Other Name Used
Date of Graduation
Social Security Number
Signature
Date of Birth
(Applicant:
Do Not Write Below This Line; Do No Detach)
Instructions to the Medical School:
Please complete “Part II - Verification of Medical School Education” below and mail this form
directly to our board office at address above.
PART II
Verification of Medical School Education
Name of Medical School
Exact Date on Medical School Diploma
During this physician’s medical school education, was he/she ever placed on probation,
No
Yes
reprimanded, censured, restricted, limited, suspended, or otherwise disciplined by the school
(except for academic or scholastic probation)?
If you responded “Yes” the above question, please provide a explanation or attach a separate sheet of explanation:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________
Signature
Date
(Seal, If Applicable)
________________________________________________________________________
Printed Name and Title
08-4022 b (Rev 09/2000)
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