Application For A License To Practice Podiatric Medicine Page 9
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2416.
Self-Designated Specialty
If you are board certified, attach a certified true copy of board certificate.
Board Certified?
Recertified
Specialty/Subspecialty
Yes/No/Year
What Board?
Date -Year
PART III
PROFESSIONAL ACTIVITIES
17. Professional Licensure
Please list all states, territories, provinces, or foreign countries in which you hold or
have ever held a license as a doctor of podiatric medicine. Include temporary,
courtesy, and locum tenens licenses, and instructional or training permits. Failure to list
If
all jurisdictions may result in disciplinary sanctions or denial.
necessary,
continue to list on a separate sheet of paper labeled with your name and signed by you.
Physician Licenses
Location (state, territory, etc.)
License Number
Date Issued
Current Status (Active, Lapsed,
etc.)
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Residency Licenses, Instructional or Training Permits
Location (state, territory, etc.)
License Number
Date Issued
Current Status (Active, Lapsed,
etc.)
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18.
Other Professional Licensure
Other than as a physician, have you ever been licensed in any jurisdiction
No
Yes
in any other profession of the healing arts?
If Yes, please complete the following:
Profession (DDS, DC, RN, PA-C, DC, etc.)
Jurisdiction (State, territory, country, etc.)
Date Licensed
Was License Disciplined?
No
Yes
No
Yes
If you have responded ‘yes’ to question 18, verifications of good standing for each license must be submitted for all other health care
professions under which you have been licensed by those jurisdictions.
Applicant Name:
Date:
08-4109 (Rev. 10/15/14)
Application
Page 3 of 9
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