Form 17598 - Application For A Temporary Medical Permit (For Postgraduate Training Or Teaching)
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1
2APPLICATION FOR A TEMPORARY MEDICAL PERMIT
(For Postgraduate Training or Teaching)
Health Professions Bureau
402 W. Washington St., Rm. 041
State Form 17598 (R6 / 9-96)
Indianapolis, IN 46204
Telephone: (317) 232-2960
Approved by State Board of Accounts 1996
Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this
record cannot be processed without it.
REQUIREMENTS AND INSTRUCTIONS TO THE APPLICANT
A. Mail completed application, along with items listed below, to the Health Professions Bureau.
1. FEE: Submit the ten dollar ($10) fee made payable to the Health Professions Bureau. Fees are non-refundable and
non-transferable.
2. PROOF OF GRADUATION: You must submit proof of graduation by submitting one of the following documents:
(a) CERTIFICATE OF COMPLETION An original letter from the Dean of your medical / osteopathic school,
stating that you have completed (not expected to) all requirements for graduation and the date when the degree
will be or was awarded.
(b) OFFICIAL TRANSCRIPT An official transcript of grades from the medical / osteopathic school, showing
degree has been conferred. Graduates of foreign medical schools must submit notarized copies of all subjects and
grades (mark sheets). Include official translation if not in english. (SEE NOTARIZED COPY NOTE)
(c) DEGREE A notarized copy of your medical / osteopathic degree. Include official translation if not in english.
(SEE NOTARIZED COPY NOTE)
3.
PHOTOGRAPH Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.
4. HOSPITAL / INSTITUTION CERTIFICATION The Hospital / Institution Certification must be completed by the
Hospital / Insitution Chairman Department Head.
PERMITS ARE NOT AVAILABLE ON A WALK-IN BASIS FROM THE BUREAU. NO EXCEPTIONS.
NOTE: If you change postgraduate programs and wish to renew your temporary permit you must file a new application.
NOTARIZED COPY NOTE: Any notarized copy of an original document must have the notary public make a statement
to the fact that the notary has seen the original document.
The Temporary Medical Permit application and requirements MUST be filed with the Health Professions Bureau at least ten (10)
days BEFORE THE RESIDENCE/TEACHING IS SCHEDULED TO BEGIN. It is a violation in the State of Indiana to practice
without a valid permit or license.
IT IS YOUR RESPONSIBILITY TO NOTIFY THE BUREAU OF YOUR PERMANENT ADDRESS ONCE IT IS ESTABLISHED.
OFFICE USE ONLY
Permit fee
Date fee paid (month, day, year)
Receipt number
$
Applicant
Permit number
Permit issuance date (month, day, year)
Attach one (1) passport
type quality photograph
APPLICANT INFORMATION
of yourself taken within
Name of applicant (last, first, middle)
Social Security number
the last eight weeks.
Address (number and street or Rural Route number)
City, state, ZIP code
Telephone number (daytime)
Date of birth (month, day, year)
Place of birth
Please indicate what address you want your permit sent to (number and street)
City, State, ZIP code
DOCTOR OF MEDICINE / OSTEOPATHIC DEGREE GRANTED BY:
Name of school
Location
Date of graduation (month, day, year)
APPLICATION AFFIRMATION
I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant
Date (month, day, year)
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