Form Dpm - Notice - Alaska Department Of Community And Economic Development printable pdf download

Form Dpm - Notice - Alaska Department Of Community And Economic Development

DPM

FOR OFFICE USE ONLY

DATE

NOTICE

The State Medical Board requires letters of standing from all hospitals where you hold or have held privileges in the past

five years.

You must request each hospital to submit a letter regarding the status of your privileges to the address below:

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

State Medical Board

P.O. Box 110806

Juneau, Alaska 99811-0806

You must complete the bottom portion of this form and return with your initial application.

If you have never held hospital privileges, please note on this form, sign and submit this

form as part of your application.

HOSPITAL

COMPLETE MAILING ADDRESS

I certify that listed above are all hospitals where I hold or have held privileges in the past five years. I understand it is my

responsibility to request these hospitals to submit a letter to the State Board to complete my application for licensure.

I certify under penalty of unsworn falsification that the above information furnished is true and correct.

Signature

WARNING: Alaska Statute 11.56.210 states

that any person who knowingly or intentionally

Date

furnishes false or fraudulent information in this

application has committed a Class A misdemeanor.

08-4109g (Rev. 10/99)

Form Dpm - Notice - Alaska Department Of Community And Economic Development