Form 08-4004e - Verification Of Licensure December 1997
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1PARAMEDIC
STATE OF ALASKA
DEPARTMENT OF COMMERCE AND ECONOMIC DEVELOPMENT
FOR OFFICE USE ONLY
DIVISION OF OCCUPATIONAL LICENSING
DATE
STATE MEDICAL BOARD
333 WILLOUGHBY AVENUE, NINTH FLOOR
P.O. BOX 110806, JUNEAU, ALASKA 99811-0806
(907) 465-2541
E-Mail: License@commerce.state.ak.us
VERIFICATION OF LICENSURE
I am applying for a license to practice as a Mobile Intensive Care Paramedic in the State of Alaska. The State Medical
Board requires that this form be completed by each jurisdiction in which I hold or have held licenses. Please complete
the form and return it directly to the Alaska State Medical Board at the above address.
NOTE: Some states require that a fee be paid in advance for providing license information. To expedite, you may wish
to contact the applicable state(s).
Name
Date of Birth:
Address
The information below must be completed by the state licensing board. It is not to be completed by the applicant.
PLEASE DO NOT DETACH
State of
Name of Licensee
Graduate of
License No.
issued effective
License is current
lapsed
revoked
Has the applicant’s license ever been suspended or revoked?
If so, for what reason, when and where?
Restrictions or conditions, if any
Derogatory information, if any
Comments, if any
If disciplinary action has been taken, please send a certified true copy of accusation, board order, and any other pertinent
documentation.
Signed
Title
(BOARD SEAL)
State Board
(All verifications must have board seal)
Date
08-4004e (Rev. 12/97)
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