Application For A License To Practice Podiatric Medicine (Page 15 of 24) in pdf



45.

Yes

Have you ever been voluntarily or involuntarily committed or confined to any facility for

mental health care?



46.

Yes

Have you ever been diagnosed with, treated for, or do you currently have (check the

appropriate condition):



Bipolar Disorder

Depressive Neurosis

Kleptomania



Hypomania

Any Dissociative Disorder

Pyromania



Schizophrenia

Any Psychotic Disorder

Delirium



Depression

Any Organic Mental Disorder

Paranoia



Seasonal Affective Disorder



Any condition requiring chronic medical or behavioral treatment



47.

Yes

Have you ever taken, or are you currently taking, any chemical substance for any of the

disorders listed in question 41 above?



48.

Yes

Have you ever been adjudicated or declared incompetent or been the subject of an

incompetency proceeding?

If you have checked “Yes” to any of the questions above, please attach a detailed explanation.

PART VI

SWORN STATEMENT

I hereby certify that I am the person herein named subscribing to this application. I have read the complete application, and I

know the full content thereof. I declare, under penalty of perjury, that all of the information contained herein and

evidence or other credentials submitted herewith are true and correct. I am the lawful holder of the degree of Doctor of

Podiatric Medicine as prescribed by this application, and that the same was procured in the regular course of instruction and

examination, and that it, together with all the credentials submitted were procured without fraud or misrepresentation or any

mistake of which I am aware and that I am the lawful holder thereof. I further certify that the photograph that appears below is a

true likeness of myself taken within the past 60 days. I understand that any falsification or misrepresentation of any item or

response in this application, or any attachment hereto or falsification or misrepresentation of credentials to support this

application, is sufficient grounds for denying, revoking, or otherwise disciplining a license or permit to practice medicine in the

state of Alaska.

I have carefully read all the instructions in the application including the instructions



under Part IV, Disciplinary History, on page 6.

Yes

Applicant Signature_____________________________________________

Date____________________________

You must sign and date this application in front of the notary public.

Applicant signature date and notary public date must be the same.

Affix a Recent

SUBSCRIBED AND SWORN TO before me, a Notary

Passport Type

Public, in and for the State of _______________________.

Photograph

this _________day of ___________________, 20____.

Here

Notary Signature_________________________________

My commission expires:___________________________

NOTE: Notary Seal Must Overlie A

Portion of the Photograph.

WARNING:

Alaska Statute 11.56.210 states that any person who knowingly or intentionally furnishes false or

fraudulent information in this application is subject to imprisonment for not more than one year, a fine of not more

than $5,000, or both.

08-4109 (Rev. 10/15/14)

Application

Page 9 of 9

Application For A License To Practice Podiatric Medicine Page 15

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