State Medical Board Biographical Data Sheet
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1DPM
STATE OF ALASKA
FOR OFFICE USE ONLY
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
STATE MEDICAL BOARD
P.O. BOX 110806
JUNEAU, ALASKA 99811-0806
(907) 465-2541
E-mail: license@dced.state.ak.us
STATE MEDICAL BOARD
BIOGRAPHICAL DATA SHEET
Name in Full:
Social Security Number:
Mailing Address:
Daytime Telephone Number:
Place of Birth:
Date of Birth:
Podiatry School:
Year Graduated:
Internship Program and Location:
Type:
Residency Program and Location:
Type:
What is your specialty?
o Yes
o No
Board Certified?
When:
Where do you intend to practice in Alaska?
Anticipated date you plan to be working in Alaska:
+
SIGN HERE
Signature of Applicant
(Place recent head and
SUBSCRIBED AND SWORN TO before me, a Notary
shoulders photograph here.)
Public, in and for the State of
this
day of
, ____.
Notary Public
My Commission Expires:
NOTE:
Notary Public Seal must overlie
a portion of the photograph
SCHEDULED APPOINTMENT:
Interview with:
Date/Day:
Time:
Confirmed with:
08-4109b (Rev. 10/99)
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