Application For A License To Practice Podiatric Medicine Page 20
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24ALASKA 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
VERIFICATION OF
STATUS OF DEA REGISTRATION
Instructions to the Applicant: Type or print legibly. Please complete Part I below and mail to the DEA.
PART I
Full Name (Last, First, Middle)
Maiden or Other Names Used:
Date of Birth (MM/DD/YYYY)
Mailing Address
City
State
Zip
Address Where DEA Registered
DEA Registration No.
Signature of Applicant
Date of Signature
MAIL THIS REQUEST FORM TO:
Drug Enforcement Administration
Attn: Diversion Unit
th
300 5
Avenue, Suite 1300
Seattle, WA 98104
FOR DEA USE ONLY
Instructions to the DEA staff: Complete Part II below. Please search your records and advise if there is any derogatory
information on file against this physician. Please return this form directly to the State
Medical Board at the letterhead address.
PART II
1. Has this applicant ever surrendered (for cause) or had a federal controlled substance
registration revoked, suspended, restricted or denied?
No
Yes
2. Is any such investigation pending?
No
Yes
DEA Comments:
08-4109e (Rev. 10/15/14)
DEA Registration Verification
ADVERTISEMENT
0 votes
Related Articles
Related forms
State Form 44614 - Application For A License To Practice Veterinary Medicine Or Registration To Practice Veterinary Technology
Financial
Application For A License To Carry A Concealed Deadly Weapon - Superior Court Of The State Of Delaware
Legal
Form Mv-372 - Application For A License To Operate A Private Service Bureau Or Open A Branch Office
Legal
Related Categories
Parent category: Legal