Application For A License To Practice Podiatric Medicine Page 7
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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 Alaska 99811-0806
A – K: 907/465-2756
L – Z : 907/465-2541
E-Mail:
medicalboard@alaska.gov
APPLICATION FOR A LICENSE TO
PRACTICE PODIATRIC MEDICINE
Nonrefundable Application Fee
$200
License Fee
$300
Total Due
$500
PART I
PERSONAL IDENTIFICATION INFORMATION
(Type or Print Legibly)
Last
First
Middle
Full Legal Name
1
(Last, First, Middle)
Other Names Used
2
(Incl. Maiden Name)
Legal Name Changes
3
(Provide copy of
documents)
Place of Birth (City, State/Country):
Sex:
Mo
Day
Year
4
Date of Birth
/
/
M
F
Facility Name and Mailing Address (Include street address if using post office box)
Full Practice Address
5
City
State
Zip Code
Duration at this
Mailing Address (Include street address if using post office box)
address:
Full Residence
6
Yrs:
Mos:
Address
City
State
Zip Code
Area Code/Phone
Area Code/Phone
7
Telephones
Work:
Home:
Preferred Address of
Use Practice Address
Use Residence Address
8
Record
(See Address of
Send my mail to this address.
Send my mail to this address.
Record information.)
Do you wish to be included on an email
emergency
9
E-Mail Address
Yes
No
notification list?
Credentials
________________________
Examination
Application Based on:
10
(Upon what state license do you base this application?)
(Not licensed in other state)
If YES, when and what type: Year:____________
Previous License or
YES
11
NO
Permit In ALASKA?
Resident
Locum Tenens
Permanent License
APPLICANT:
As required by state law, please provide your United States Social Security Number in the space below. It is considered
CONFIDENTIAL information and is not for public disclosure.
Applicant’s Social Security Number __________________________________________
08-4109 (Rev. 10/15/14)
Application
Page 1 of 9
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