Form 08-4109f - Board Action Data Bank Inquiry Form - Department Of Community And Economic Development - Alaska

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DPM
FOR OFFICE USE ONLY
BOARD ACTION DATA BANK INQUIRY FORM
TO THE APPLICANT:
Complete the identifying information and submit fee of $5.00 to:
Federation of Podiatric Medical Boards
P.O. Box 33285
Washington, DC 20033
The State Medical Board requests a Board Action Research concerning the following individual:
Practitioner’s Name (Last, First, Middle, Maiden)
Degree
Date of Birth (yy/mm/dd)
Social Security Number
Medical School
Include Complete Name and Branch Location
Year of Graduation
Country of Podiatry School
ECFMG Number (if foreign medical graduate)
+
PLEASE MAIL THE RESPONSE TO:
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
State Medical Board
P.O. Box 110806
Juneau, Alaska 99811-0806
Practitioner’s Signature:
Date:
FOR FEDERATION USE ONLY
08-4109f (Rev. 10/99)

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