Application For A License To Practice Podiatric Medicine Page 17
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ALASKA STATE MEDICAL BOARD
For Office Use Only
Department of Commerce, Community, and Economic Development
Division of Corporations, Business, and Professional Licensing
(333 Willoughby Avenue – Ninth Floor)
Post Office Box 110806
Juneau AK 99811-0806
A – K: 907/465-2756
L – Z: 907/465-2541
E-Mail: medicalboard@alaska.gov
VERIFICATION OF LICENSURE
Instructions to the Applicant:
Please complete Part I below and forward a copy of this form to all states, territories, or other countries’
licensing jurisdictions where you have ever been licensed. Copy this form as needed. Please type or print
legibly.
PART I
Full Name (Last, First, Middle)
Maiden or Other Names Used:
Date of Birth (MM/DD/YYYY)
Mailing Address
City
State
Zip
Medical/Osteopathic School Attended
Location
Year of Graduation
Signature of Applicant
Date of Signature
FOLLOWING TO BE COMPLETED BY STATE BOARD OR OTHER LICENSING JURISDICTION ONLY
Instructions to the licensing agency:
Please complete Part II below for the physician identified above and return this document directly to
the Alaska State Medical Board.
PART II
LICENSING
LICENSE NUMBER
JURISDICTION
INITIAL ISSUE DATE
EXPIRATION DATE
BASIS OF LICENSURE
CURRENT LICENSE
(FLEX, USMLE, etc.)
STATUS
1
Has this applicant ever been the subject of an investigation by a licensing or disciplinary
No
Yes
authority in your state or jurisdiction?
2
Is any such investigation pending?
No
Yes
3
Have formal disciplinary proceedings been initiated against this applicant or the
No
Yes
applicant’s license by a licensing or disciplinary authority in your state or jurisdiction?
4
Is any such action pending?
No
Yes
5
Has this applicant’s license ever been suspended, revoked, disciplined, restricted,
No
Yes
warned, placed on probation, or in any other manner limited by a licensing or
disciplinary authority in your state?
6
To your knowledge, is there any derogatory information regarding this applicant?
No
Yes
_______________________________________
___________________
Signed by
Date
(Board Seal)
______________________________________
______________________________________
Printed Name
Title
08-4109b (Rev. 10/15/14)
Verification of Licensure
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