Form 08-4004f - Add/change Of Mobile Intensive Care Paramedic Sponsor - Alaska Department Of Commerce And Economic Development

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PARAMEDIC
STATE OF ALASKA
FOR OFFICE USE ONLY
DEPARTMENT OF COMMERCE AND ECONOMIC DEVELOPMENT
DATE
DIVISION OF OCCUPATIONAL LICENSING
STATE MEDICAL BOARD
P.O. BOX 110806
JUNEAU, ALASKA 99811-0806
(907) 465-2541
E-Mail: License@commerce.state.ak.us
ADD/CHANGE OF MOBILE INTENSIVE CARE PARAMEDIC SPONSOR
TO THE APPLICANT AND PHYSICIAN SPONSOR:
The Alaska Mobile Intensive Care Paramedic Licensure Regulations (12 AAC 40.300 - 12 AAC 40.390) require that the
applicant for licensure submit a letter from his or her physician sponsor attesting that he/she is capable of performing the
activities listed in 12 AAC 40.370(a) entitled “Scope of Authorized Activities.” A copy of this section can be found on the reverse
side of this form. Following completion by the Physician Sponsor, please return it directly to the address above.
Check One:
Additional Sponsor:
Change of Sponsor:
Paramedic’s Name:
Address:
Employer’s Name:
Address:
Scope of Job Duties:
Alaska Paramedic License Number:
Daytime Telephone Number:
This letter is in reference to the application for licensure as a Mobile Intensive Care Paramedic submitted by
.
As the Current Physician Sponsor, I endorse
‘s skills as a mobile
intensive care paramedic and endorse licensure of this individual under my supervision.
Printed Name of Physician Sponsor
Signature of Physician Sponsor
License Number:
Date:
SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of
this
day of
19
.
NOTARY SEAL
Notary Public
My Commission Expires:
08-4004f (Rev. 12/97)

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