Medical School Verification Ua Form 2 Iowa Board Of Medicine

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Medical School Verification (UA Form #2)
Applicant: Complete this form as instructed in the left sidebar.
Dean or Designated Med School Official: Complete as instructed in the left sidebar.
Applicant:
Section 1: Applicant Information
This form is not
Last name: ______________________________________________________________ Suffix: ________
needed if you are
using FCVS for
First name: ____________________________________________________________________________
credentials
verification.
Middle name: __________________________________________________________________________
Complete Section 1
and fill in your name
Name if different when diploma awarded: ____________________________________________________
at the top of page 2.
Type or print legibly.
Name of medical school: __________________________________________________________________
Send this form and a
Date of birth: _______________________
Social Security number*: _____________________________
copy of your medical
school diploma to the
*The social security number is to be used for purposes of identification only and may not be used for any other reason.
current Dean of your
medical school.
Waiver for Release of Information: I authorize the medical school listed above to provide any and all
Copy this form for
information pertaining to my medical education at that institution to the Board listed below. I request that the
multiple schools.
Dean or a designated official complete Section 2 of this form and seal the copy of my diploma (attached),
then return this form, the sealed diploma copy, and a copy of my official transcripts to the Board listed below
at the given address.
Use the medical board
Board name:
_______________________________________________________________________
directory located at
Mailing address: _______________________________________________________________________
policy/contacts
to
City/State/Zip:
_______________________________________________________________________
ensure you list the
correct name/address.
Applicant signature: _______________________________________________ Date: _______________
Dean or Designated
Section 2: Medical School Verification
Official:
Please complete
Medical school name: ____________________________________________________________________
Section 2 of this form
and certify the
School name if different when the above applicant attended: ______________________________________
enclosed copy of the
above named
Medical school address (including city, state or province, zip code, and country as applicable):
applicant’s diploma by
placing your school
______________________________________________________________________________________
seal on it.
______________________________________________________________________________________
Mail the sealed
diploma copy and an
official copy of the
Hours of undergraduate education required for admission into your school: __________________________
transcripts of the
above named physician
Total weeks of education applicant attended your school: ________________________________________
with this form and any
attachments to the
Applicant’s attendance dates: From ___________________________ to ____________________________
state board listed in
Section 1.
Graduation date: __________________________ Degree: _______________________________________
(indicate N/A if not applicable)
(indicate N/A if not applicable)
DO NOT MAIL THIS
FORM TO FCVS/FSMB.
The questions on the following page apply to unusual circumstances that occurred during any part of the
If transcripts are not in
individual’s medical education. Please check the appropriate response(s) and provide dates and requested
English, an original,
certified, and official
information. “Yes” responses to any of these questions require a copy of explanatory records or a written
English translation is
required.
explanation. Attach additional pages as necessary.
Uniform Application for Physician State Licensure
DO NOT SEND THIS FORM TO FCVS/FSMB.
Medical School Verification Form
11/2014
Refer to the left sidebar to determine where to mail this form.
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