Application For A License To Practice Podiatric Medicine Page 8
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2412. Military Service
Have you ever been in the armed forces?
No
Yes
:_________________________
_________________
If YES, branch of service
Date of commission:
______________________________________________________
Date and Type of Discharge:
:______________________________________________________
Locations where you served
PART II
EDUCATION
13. Podiatric Medical School Education
List the podiatric medical school(s) you attended and from which you
graduated. If you attended more than one school, provide your reason for
changing schools on a separate sheet of paper signed and dated by you.
Completed
Yr
SCHOOL
MAILING ADDRESS
(MM/YYYY)
Yes/No
From
1
To
From
2
To
From
3
To
From
4
To
14. Postgraduate Training
List internship, residency, or fellowship training programs chronologically. You must have
at least one year of surgical post-graduate training.
Completed
Yr
HOSPITAL
MAILING ADDRESS
(MM/YYYY)
Yes/No
From
1
To
From
2
To
From
3
To
From
4
To
15.
Examination History
P
lease specify National Boards or PMLexis, or a state written examination.
Exam Series
Location
Date Taken (MM-YYYY)
Result
Pass
Fail
Pass
Fail
Pass
Fail
Applicant Name:
Date:
08-4109 (Rev. 10/15/14)
Application
Page 2 of 9
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