Application For A License To Practice Podiatric Medicine (Page 18 of 24) in pdf

Application For A License To Practice Podiatric Medicine Page 18

ALASKA STATE MEDICAL BOARD

MED

Department of Commerce, Community, and Economic Development

For Office Use Only

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

LIST OF HOSPITALS

WHERE PRIVILEGED

Instructions to the Applicant:

Type or print legibly. List below all hospitals where you currently hold or have held privileges in the last five

years. If you have not held privileges within the past five years or never held privileges, please write “None” on

this form, sign it, and submit this form as part of your application. Please include residency privileges if

appropriate.

WHEN PRIVILEGED

HOSPITAL

MAILING ADDRESS

(MM/YYYY)

From

I certify that listed above are all hospitals where I hold or have held privileges in the past five years. I understand it is my

responsibility to request these hospitals submit a letter to the board to complete my application for licensure. I certify under

penalty of unsworn falsification that the above information is true and correct.

Signature

_________________________________________

Date

_________________________________________

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

information in this application has committed a Class A misdemeanor.

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

List of Hospitals

Application For A License To Practice Podiatric Medicine Page 18