Form 08-4226 - Application For Physician Assistant - Alaska Department Of Community And Economic Development

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ALASKA STATE MEDICAL BOARD
Department of Community and Economic Development
Office Use Only
Division of Occupational Licensing
3601 C Street - Suite 722
Anchorage AK 99503-5934
(907) 269-8163
E-Mail: license@dced.state.ak.us
APPLICATION FOR
PHYSICIAN ASSISTANT
Certified
Graduate
PART I
Personal Information -
Please type or print legibly
NAME
Last:
First:
Middle:
ADDRESS
CITY, STATE, ZIP
E-MAIL ADDRESS
WORK PHONE
HOME PHONE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
Sex:
F
M
Month:
Day:
Year:
PART II
Education -
List all relevant education.
Degree/Certificate Earned
Name of School
Location
And In What Discipline?
Year Earned
PART III
Employment History
List all relevant work experience, such as nursing experience. Explain any
-
gaps of employment/practice of thirty days or more since obtaining PA
certificate .
Employer
Location: City, State
Dates
Title
(Attached a separate sheet if necessary.)
08-4226 (Rev 11/2000)
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