Application For A License To Practice Podiatric Medicine Page 23
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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 POSTGRADUATE TRAINING
Instructions to the Applicant:
Type or print legibly. Complete Part I below and send to the post-graduate training program(s) you attended.
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 (Name and Location)
Yr of Graduation
If IMG, ECFMG No.
Signature of Applicant
Date
NAME OF POSTGRADUATE PROGRAM _____________________________________________________________________________________
ADDRESS _____________________________________________________________________________________
FOLLOWING TO BE COMPLETED BY POST-GRADUATE PROGRAM STAFF ONLY
PART II
Post-graduate Training Program:
Please complete the information requested below and return this document directly to the Alaska board
at the letterhead address.
VERIFICATION FOR:
PPMR
PSR-12
PSR-24
PM&S-24
PM&S-36
POR
Exact Dates of Training _____________________________________________________________________________
1
At the time this individual completed training in your program, was the program accredited through the Council on
Podiatric Medical Education?
Yes
No
2
During the physician’s participation in your program, was he/she ever investigated or disciplined by the program,
such disciplinary actions to include but not be limited to, being placed on probation, issued a letter of reprimand or
warning, censured, suspended from the program, restricted, or otherwise disciplined? If you respond “Yes” to this
question, please attach a separate sheet providing a detailed explanation of the action and the reason for the
action.
No
Yes
3
Is there anything in this physician’s postgraduate training records that would indicate he/she would be unable to
practice medicine competently and safely? If “Yes”, please attach a detailed explanation.
No
Yes
___________________________________________
_______________________
(SEAL, If Applicable)
Signature
Date
___________________________________________
_______________________
Printed Name
Title
08-4109i (Rev. 10/15/14)
Post-Graduate Training Verification
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