Application For A License To Practice Podiatric Medicine Page 21
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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
BOARD ACTION DATA BANK INQUIRY
Instructions to the Applicant:
Type or print legibly. Complete Part I below. Mail this form to the Federation at the address below.
PART I
Full Name (Last, First, Middle)
Maiden or Other Names Used:
Date of Birth (MM/DD/YYYY)
Mailing Address (Street)
Place of Birth
City/State/Zip
If International Grad., ECFMG No.
Medical/Osteopathic School (Name and Location)
Year of Graduation
YOU MUST MAIL THIS FORM TO:
Federation of Podiatric Medical Boards
6551 Malta Drive
Boynton Beach FL 33437
FOLLOWING TO BE COMPLETED BY DATA BANK STAFF ONLY
PART II
Instructions to the Data Bank Staff:
Please search the data bank for any record of this practitioner. Please forward
your report to the medical board at the letterhead address.
FOR FEDERATION USE ONLY
08-4109f (Rev. 10/15/14)
FPMB Data Bank Verification
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