Application For A License To Practice Podiatric Medicine Page 10
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2419. Medical Societies and Professional Organizations
Name of Organization
Address
Date From/To - YYYY
20. Hospital Affiliations
Have you ever held hospital privileges?
No
Yes
If Yes, please list all hospitals in which you have been credentialed within the immediate past five years.
WHEN PRIVILEGED
HOSPITAL
MAILING ADDRESS
(MM/YYYY)
From
1
To
From
2
To
From
3
To
From
4
To
From
5
To
If necessary, continue to list of a separate sheet of paper labeled with your name and signed by you.
21. Medical Work History
Please provide a chronological listing of all medical and non-medical activities
beginning with your graduation from medical school to the present date with no more
than a 60-day gap in time. You may attach a detailed curriculum vitae as long as all
information is included. Please explain any gap in time from practice of more
than sixty (60) days’ duration.
Date
Location
(MM/YYYY
)
(City, State, or Other Country)
Activity
Fr
To
Fr
To
Fr
To
Continued on next page
Applicant Name:
Date:
08-4109 (Rev. 10/15/14)
Application
Page 4 of 9
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