Form 08-4021 D - Request For Extension Locum Tenens Permit - Alaska
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1ALASKA STATE MEDICAL BOARD
MED
Department of Community and Economic Development
For Office Use Only
Division of Occupational Licensing
(333 Willoughby Avenue - Ninth Floor)
Post Office Box 110806, Juneau Alaska 99811-0806
(907) 465-2541
E-Mail:
license@dced.state.ak.us
Receipt No.
Amount
REQUEST FOR EXTENSION
LOCUM TENENS PERMIT
Instructions:
State law provides for the initial issuance of a locum tenens permit with a maximum of three extensions. Extensions must
be specifically requested in advance and must be processed prior to the expiration of the original permit. To request a
locum tenens extension, please complete this form and return it to the board at the letterhead address at least two weeks
prior to the expiration of the original permit. This form must be signed by a representative of the hospital, clinic, or staff
manager of the office where the locum physician is employed. PLEASE INCLUDE FEE OF $100 WITH THIS REQUEST.
Locum Tenens Physician (Last, First, Middle)
Locum Tenens
Alaska Permit Number
Alaska Physician for whom
Locum Tenens
Working Locum
Permit Expiration Date
Reason for the Request for Extension: _________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Brief Comment on the Performance of
the Locum Tenens Physician:
_______________________________________________________________________
_________________________________________________________________________________________________
Extension Requested by:
________________________________________________
______________________________________
(Printed Name & Title, Hospital, Clinic, or Office Repr)
Signature
Date
NOTE:
1)
Faxed requests will not be processed. Request must be accompanied by appropriate fee.
2)
If permit expires before extension is granted, you must reapply for a new permit, pay the total $200 initial
application fee, and resubmit all documents.
Request for Extension of Locum Tenens Permit Approved:
___________________________________________________
_______________________________
Signature, Designee of the Board
Date
08-4021 d (Rev 09/2000)
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