Application For A License To Practice Podiatric Medicine Page 12
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24SPECIAL INSTRUCTIONS FOR PARTS IV AND V IV A
ND V
In responding to the questions in Parts IV and V below, please check the appropriate box next to each question. A “Yes”
response to a question does not automatically result in a denial of license application. For each “Yes” response to any
question, you must provide an explanation and documentation. Provide your explanation on a separate sheet of
paper labeled with your name, and signed by you; include full details, dates, locations, type of action, organizations or
parties involved, and specific circumstances. When in doubt about your response, disclose and provide the explanation
requested. Please answer parts A and B of each question. Documentation includes copies of court orders, charging
documents, board or license actions, etc.
CONFIDENTIALITY
The contents of licensing files are generally considered public records. If you believe that the additional information you are
attaching to explain a “yes” answer should be considered confidential, state that in the attachment. A request for confidentiality
may or may not be granted.
PART IV
DISCIPLINARY HISTORY
IMPORTANT! PLEASE READ BEFORE ANSWERING
THE DISCIPLINARY HISTORY QUESTIONS
For the purposes of this application, the word “discipline” is used. There are many forms of disciplinary
actions that may be imposed by organizations, schools, programs, licensing authorities, and other agencies.
Such disciplinary actions may include but not be limited to: Suspension, Surrender, Revocation, Probation,
Academic Probation, Reprimand, Censure, Restricted License, Limited License, Conditioned License, or
Letters of Counseling, Concern, Advice, Warning, Caution, Admonishment, Reprimand, etc. Please include
non-reported disciplinary actions. Failure to disclose past history may be grounds for disciplinary sanctions.
WHEN IN DOUBT, DISCLOSE AND EXPLAIN.
24a.
No
Yes. . . . . .Have you ever been convicted of a crime (felony or misdemeanor) in any jurisdiction of
the United States, including military, or any international jurisdiction?
24b.
No
Yes. . . . . . Is any such action pending?
25a.
No
Yes. . . . . . Have you ever been charged with a crime (felony or misdemeanor) in any jurisdiction of
the United States, including military, or any international jurisdiction that did not result in
acquittal or dismissal?
25b.
No
Yes. . . . . . Is any such action pending?
26a.
No
Yes. . . . . . Relating to the practice of medicine, has there ever been a finding of, or have you ever
been found guilty of, professional misconduct, unprofessional conduct, incompetence, or
negligence, by any jurisdiction of the United States, including military, or any international
jurisdiction?
26b.
No
Yes. . . . . . Is any such action pending?
27a.
No
Yes. . . . . . Relating to the practice of medicine, have you ever had charges filed against you alleging
professional misconduct, unprofessional conduct, incompetence, or negligence, in any
jurisdiction of the United States, including military, or any international jurisdiction?
27b.
No
Yes. . . . . . Is any such action pending?
Continued on next page
Applicant Name:
Date:
08-4109 (Rev. 10/15/14)
Application
Page 6 of 9
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