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Form Dpm/pgy1 - Application For License To Practice Podiatry In The State Of Alaska - Department Of Community And Economic Development

DPM/PGY1

State Of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

State Medical Board

P.O. Box 110806

Juneau, Alaska 99811-0806

I am applying for a license to practice podiatry in the State of Alaska. The State Medical Board requires independent

verification of my completion of Post Graduate Year 1 (PGY1) in a surgical residency. Please complete this form and

return it directly to the address above. Please consider my signature below as authorization to honor such request.

Thank you for your assistance.

RE:

Name:

, D.P.M.

Maiden Name or Other Names Used:

Date of Birth:

Social Security Number:

Signature of Physician/Applicant

(Below to be completed by Internship Program Supervisor)

Podiatry School:

Exact Date on Podiatry School Diploma:

PGY1 Surgical Residency Completed at:

Dates:

Were there any disciplinary problems noted while this individual was in his/her PGY1 term or any other time during which

o Yes

o No

he/she was attending your program?

If yes, please explain:

o Yes

o No

Was this individual ever placed on any kind of probationary status resulting from disciplinary action?

If yes, please give nature and length of probation:

Signed:

SEAL

Title:

(if applicable)

Program:

Date:

08-4109i (Rev. 10/99)

Form Dpm/pgy1 - Application For License To Practice Podiatry In The State Of Alaska - Department Of Community And Economic Development