Application For A License To Practice Podiatric Medicine Page 24
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24Request for NBPME APMLE Scores
Please print clearly, neatly, and completely.
Candidate Information
Last Name (at time you took the exam)
First Name
Middle Initial
Date exam was taken
Year of Graduation
Email Address
Home Phone Number (including area code)
(
)
Social Security Number (optional)
Check scores to be sent:
Part I
Part II
Your Address Information.
Please print YOUR full name and address below.
This information will be used as the return address when your scores are sent.
Current Name
Address
City/State/Zip
Recipient’s Address Information.
Please print the exact name, office and address to which scores are to be sent.
Name
Address
City/State/Zip
Current Signature: ____________________________________________________
Date: ________________________
(Your signature provides authorization for NBPME and Prometric to release your records as you indicated above.)
Payment Information
The score report request fee is $35. This fee covers the transmittal of Part I and Part II scores and must
accompany each request.
•
If paying by
certified check, cashier’s check, or money
order: Mail this completed form and payment to:
PROMETRIC/NBPME, 1260 Energy Lane, St. Paul, MN 55108.
•
If paying by
credit
card: Complete the information below and FAX to 800.813.6670.
Card Type (Check One)
Card Number
Expiration Date
MasterCard
Visa
Name of Cardholder (Print)
Signature of Cardholder
Revised 20110802
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