FOR OFFICE USE ONLY
The State Medical Board requires letters of standing from all hospitals where you hold or have held privileges in the past
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.
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.
WARNING: Alaska Statute 11.56.210 states
that any person who knowingly or intentionally
furnishes false or fraudulent information in this
application has committed a Class A misdemeanor.
08-4109g (Rev. 10/99)