Application For A License To Practice Podiatric Medicine Page 13
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28a.
No
Yes. . . . . . Has any hospital or other health care facility disciplined, restricted, or terminated your
professional training, employment, or privileges, or investigated a complaint or accusation
regarding your practice (except for late medical records)?
28b.
No
Yes. . . . . . Is any such action pending?
29a.
No
Yes. . . . . . Have you ever voluntarily or involuntarily resigned or withdrawn from professional
training, from employment, or your privileges from any hospital or other health care facility
to avoid the imposition of disciplinary sanction, restriction, or termination?
29b.
No
Yes. . . . . . Is any such action pending?
30a.
No
Yes. . . . . . Have you ever been disciplined* by a medical school or post-graduate training program?
(*See ‘Important Information’ block on discipline on page 6.)
30b.
No
Yes. . . . . . Is any such action pending?
31a.
No
Yes. . . . . . Have you ever had a license to practice medicine disciplined by any authority including a
state medical board or a military authority (except for late medical records)?
(If you are unsure about your response to this question, please refer to the instructions and definitions for this
section on page 6 of this application above. When in doubt, disclose and explain.)
31b.
No
Yes. . . . . . Is any such action pending?
32a.
No
Yes. . . . . . Have you ever been under investigation, notified of an investigation, or contacted by a
board investigator or enforcement officer for any medical licensing jurisdiction or
authority?
(If you are unsure about your response to this question, please refer to the instructions and definitions for this
section on page 6 of this application above. When in doubt, disclose and explain.)
32b.
No
Yes. . . . . . Is any such action pending?
33a.
No
Yes. . . . . . Have you ever had a medical license application denied by any medical licensing
jurisdiction or authority?
33b.
No
Yes. . . . . . Is any such action pending?
34a.
No
Yes. . . . . . Have you ever voluntarily or involuntarily withdrawn an application for a license to
practice medicine in any United States jurisdiction or any international jurisdiction?
34b .
No
Yes. . . . . . Is any such action pending?
35a.
No
Yes. . . . . . Have you ever voluntarily or involuntarily surrendered or suspended your license to
practice medicine in any United States jurisdiction or any international jurisdiction?
35b.
No
Yes. . . . . . Is any such action pending?
36a.
No
Yes. . . . . . Have you ever voluntarily or involuntarily agreed to any limitations, restrictions, or
conditions to your license to practice medicine?
36b.
No
Yes. . . . . . Is any such action pending?
37a
No
Yes. . . . . .Has your employment by a clinic, hospital, or other health care organization ever been
terminated involuntarily or voluntarily as a result of an actual or potential investigation or
as grounds for disciplinary proceedings?
37b
No
Yes. . . . . .Is any such action pending?
Applicant Name:
Date:
08-4109 (Rev. 10/15/14)
Application
Page 7 of 9
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