Application For A License To Practice Podiatric Medicine Page 22
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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
VERIFICATION OF PODIATRIC MEDICAL
SCHOOL EDUCATION
Instructions to the Applicant:
Type or print legibly. Complete Part I below and send to the medical school from which you received your
diploma.
PART I
Full Name (Last, First, Middle)
Maiden or Other Names Used:
Date of Birth (MM/DD/YYYY)
Mailing Address
City
State
Zip
Signature of Applicant
Date of Signature
Full School Name
______________________________________________________________________
Location
______________________________________________________________________
FOLLOWING TO BE COMPLETED BY MEDICAL SCHOOL STAFF ONLY
PART II
Instructions to the Medical School:
Please complete the information below and return this document directly to the Alaska board at the letterhead
address.
Exact Date on School Diploma ______________________________________________________________________
During this physician’s medical school education, was he/she ever investigated by the school or disciplined by the school
for any reason? Disciplinary actions include but are not limited to being placed on probation, issued a letter of reprimand,
censured, suspended, restricted, or otherwise disciplined.
No
Yes
If you responded “Yes” to this question, please provide a detailed explanation of the action and the reason for the action on
a separate sheet of paper attached to this form signed and dated by the person whose signature appears below.
Signed __________________________________________________
Original signature only, signature stamps are not accepted.
Printed Name __________________________________________________
(SEAL, If Applicable)
Title __________________________________________________
Date __________________________________________________
08-4109h (Rev. 10/15/14)
School Verification
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