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.
Maiden Name or Other Names Used:
Date of Birth:
Social Security Number:
Signature of Physician/Applicant
(Below to be completed by Internship Program Supervisor)
Exact Date on Podiatry School Diploma:
PGY1 Surgical Residency Completed at:
Were there any disciplinary problems noted while this individual was in his/her PGY1 term or any other time during which
he/she was attending your program?
If yes, please explain:
Was this individual ever placed on any kind of probationary status resulting from disciplinary action?
If yes, please give nature and length of probation:
08-4109i (Rev. 10/99)