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Full name*
Have you ever legally changed your name?*
- Yes
- No
Previous Legal Name
Date of name change
Date Format: MM slash DD slash YYYY
Reason for change

Email*
Address*
Home street address Home city Home State Home ZIP
Cell phone number*

Date of Birth*
Date Format: MM slash DD slash YYYY
Are you a U.S. citizen?*
- Yes
- No
Social security number*
Have you ever served in the U.S. Military?*
- Yes
- No

Height (ft.in)*
Weight (lbs)*
Eye color*
Hair color*
Race*
If other, please specify*
Gender*
- Male
- Female

Please list all educational facilities in chronological order, beginning with high school.
Education
School Type*
School name*
School country*
School state/province(Foreign)*
Is this school foreign to the U.S.?*
Yes
No
Did you attend a Fifth Pathway?
Yes
No
Were clerkships complete in your country of graduation?
Yes
No
Were clerkships completed in the U.S.?
Yes
No
if so, please fax or mail a list of the clerkships that were performed in the U.S.
ECFMG Number
Did you graduate from this school?*
Yes
No
Any unusual circumstances? (e.g. time off, disciplinary action, retaking classes)*
Yes
No
Please Explain

Postgraduation
List all Postgraduate training performed in the US.
Type of Program*
If other, please specify
Facility name*
Accreditation*
Department*
Start Date*
Date Format: MM slash DD slash YYYY

End date
Date Format: MM slash DD slash YYYY

Did you complete this program?*
Yes
No
Any unusual circumstances? (e.g. time off, disciplinary action, retaking classes)*
Yes
No
Please Explain

List all licensing exams taken in the US.
Exam
Exam Taken
If other, please specify
State Where Taken
Exam Date*
Date Format: MM slash DD slash YYYY

Number of Attempts*
Did you pass the last attempt?
Yes
No
NPI
List all US medical licenses that have ever been issued to you.
Licence
State*
License type*
Has any action(s) been taken against your license?
Yes
No
Please Explain
No Are you registered with the DEA?
Yes
No
DEA registration number
State issued

List all US Board Certifications that have ever been awarded to you.
Certification
Speciality*
Did you lifetime certified?
Yes
No
Date certified*
Date Format: MM slash DD slash YYYY

Date recertified*
Date Format: MM slash DD slash YYYY

Sub speciality

Employment
List in order of chronology from date of completion of postgraduate training, to present, all employment, including staff affiliations.
Employer name*
Employment type*
Employer city*
Employer state*
Employer ZIP*
Job title*
Start Date*
Date Format: MM slash DD slash YYYY

End date
Date Format: MM slash DD slash YYYY

Any unusual circumstances? (e.g. time off, disciplinary action, retaking classes)*
Please Explain

Malpractice
List all malpractice cases that have ever been filed against you.
Have you ever had a malpractice
Yes
No
Disposition date
Date Format: MM slash DD slash YYYY

Please provide a brief description of the complaint, plaintiff name, case number, policy number, and outcome of the case. Also include the county where the case was filed.

Notes
I understand that the following questions, if answered incorrectly, may result in adverse actions by the medical board up to and including denial of licensure.*
- I Agree
Have you ever been the subject of any disciplinary or adverse action in medical school, postgraduate training, or during your professional career? If yes, please explain below.*
- Yes
- No
Have you ever been named in a malpractice suit? Provide dates and basic details below. We will let you know if the board requires further information.*
- Yes
- No
Have you ever been arrested or charged with a felony or misdemeanor, including DUI or DWI? If yes, please explain below.*
- Yes
- No

Sign
Please put your sign here*

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