Form 08-4004a - Verification Of Paramedic Internship Training

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STATE OF ALASKA
FOR OFFICE USE ONLY
DEPARTMENT OF COMMERCE AND ECONOMIC DEVELOPMENT
DATE
DIVISION OF OCCUPATIONAL LICENSING
STATE MEDICAL BOARD
P.O. BOX 110806
JUNEAU, ALASKA 99811-0806
(907) 465-2541
E-Mail: License@commerce.state.ak.us
VERIFICATION OF PARAMEDIC INTERNSHIP TRAINING
Paramedic’s Name:
Address:
Dear Dr.
I am applying for licensure as a Mobile Intensive Care Paramedic in the State of Alaska. It is a requirement that the information
below be completed and notarized by the physician who was responsible for supervision during my paramedic internship training.
Please complete this form and return it directly to the address above. Thank you for your assistance.
Signature of Paramedic/Applicant
PARAMEDIC INTERNSHIP (See reverse)
I hereby certify that
was under my supervision during his/her paramedic
internship in
(location), from
to
and that I further certify that she/he successfully completed the
internship requirements per 12 AAC 40.310(5) and 12 AAC 40.325 (see reverse side) and she/he is capable of performing the
activities listed in 12 AAC 40.370(a). I recommend him/her for licensure as a mobile intensive care paramedic.
Print Name (Supervising Physician)
Signature (Supervising Physician)
States in which licensed and license number:
SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of
this
day of
19
.
NOTARY SEAL
Notary Public
My Commission Expires:
08-4004a (Rev. 12/97)

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