Certification Of Medical Education For (Page 2 of 2) in pdf

Certification Of Medical Education For Page 2

THIS SIDE TO BE COMPLETED BY

THE DEAN OR REGISTRAR OF MEDICAL SCHOOL

Please complete the following information. Return this completed certification directly to the University of

Michigan Hospitals and Health Centers, Medical Staff Services at the address shown on the reverse side of

this form.

SECTION II - CERTIFICATION OF MEDICAL EDUCATION

Name of Medical School

Street Address of Medical School

City, State and ZIP Code

I certify that ____________________________________________________________________ attended the

(Applicant’s Name)

medical school named above from ____________________________, to ______________________,

(MM/DD/YY)

and was granted the degree of ________________________________________________________.

on ____________________________________, _______.

(

YYYY)

________________________________________________

____________________________

(Signature of Dean or Registrar)

Date of Signature

_________________________________________________

Print or Type Name of Dean or Registrar

S E A L

__________________________________________________

Email address

If school has no seal, please

indicate.

Version 1-2-08

Certification Of Medical Education For Page 2