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Step 1 of 12 - General

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  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Please list all educational facilities in chronological order, beginning with high school.

  • Education

    if so, please fax or mail a list of the clerkships that were performed in the U.S.

  • Postgraduation

    List all Postgraduate training performed in the US.

    Date Format: MM slash DD slash YYYY
    Date Format: MM slash DD slash YYYY
  • List all licensing exams taken in the US.

  • Exam
    Date Format: MM slash DD slash YYYY
  • List all US medical licenses that have ever been issued to you.

  • Licence
  • List all US Board Certifications that have ever been awarded to you.

  • Certification
    Date Format: MM slash DD slash YYYY
    Date Format: MM slash DD slash YYYY
  • Employment

    List in order of chronology from date of completion of postgraduate training, to present, all employment, including staff affiliations.
  • Date Format: MM slash DD slash YYYY
    Date Format: MM slash DD slash YYYY
  • Malpractice

    List all malpractice cases that have ever been filed against you.
    Date Format: MM slash DD slash YYYY
  • Notes

  • Sign

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