Medical License Direct
Solution for your medical license needs.
PHONE: 850-471-8648
FAX: 904-339-9671
4020 Collingswood Rd.
Pensacola, FL 32514
info@medicallicensedirect.com
Personal Information:
First Name                         Middle                     Last Name                      M.D or D.O?                 Suffix                     Social Security #
Home address                                    City                           State      Zip                      Home Tele#            Cell Phone #
Work address                                       City                           State     Zip                      Work Tele #
Preferred mailing address:
Home
Work
Email address:
Marital                                    Maiden or Previous Name/s                         Dates for previous name                              Birth Date
Status
Birth Place                                              US Citizen?                                                                       Languages Spoken/Read
(city/state/country)
U.S. Military Experience:
Branch                Dates of Service                              Rank                                   Discharge Status                 Discharge Date
Physical Characteristics:
Height                  Weight                Gender                       Eye Color                     Hair Color                                Race
Physical Marks                                                                                Location
Education: List all undergraduate, graduate and medical education beginning with high school.
Institution                                 City/State                              Program of Study          Dates: From / To                  Degree Awarded
Exact medical school graduation date:
Month/Day/Year
Foreign Medical Graduates:
Did you attend a fifth pathway program?
Yes
No
ECFMG Certificate #
Issue Date
Did you complete clinical clerkships in a country
other than where your medical school is located?
If you answer "Yes" please provide us with a
copy of the clerkships performed in the U.S.
Yes
No
Medical Exam History: List all licensing exams you have ever taken including FLEX, USMLE,
SPEX, NBME, NBOME, LMCC or SBME.
Exam                                       Part/Step                        Date Taken                                   State                                        # of Attempts
If applicable: Number of Years to complete all 3 Steps of USMLE:
Post Graduate Training : List all U.S. internships, residencies and fellowships in date order
whether completed or not.
PGY 1 Facility Name                                              Address, City, State                                      Program Director's Name
*Program Type/Department                                 Dates: From /To                                                      Certificate Earned?
PGY 2 Facility Name                                               Address, City, State                                      Program Director's Name
*Program Type/Department                                 Dates: From /To                                                      Certificate Earned?
PGY 3 Facility Name                                               Address, City, State                                      Program Director's Name
*Program Type/Department                                 Dates: From /To                                                      Certificate Earned?
PGY 4 Facility Name                                               Address, City, State                                      Program Director's Name
*Program Type/Department                                 Dates: From /To                                                      Certificate Earned?
*All above programs were ACGME approved.
Yes
No
Any comments... additional information or training... unusual circumstances?
DEA #
Date Issued:
Date Expires:
Do you have a Federation Credential Verification Service (FCVS) Profile established or in process?
Yes
No
If Yes - FCVS Profile #
Medical Licenses: List all ever held regardless of current status.
Status
State
Type
Number
Issue Date
Exp. Date
Original state of licensure:
Date you legally first began to practice medicine:
(mm/dd/yy)
Practice / Employment / Hospital Affiliation History: Medical license applications require all time
be accounted for since graduation from medical school. Please list all activities (except PGT)
including employment, hospital affiliations (note type of privilege), locum tenens assignments,
unemployment and vacation since graduation from medical school. You may substitute your CV
if there are no gaps. Be sure to include month and year.
Practice/employment/hospital                         Address                                                              Dates: From / To             Type  
Certification:
Are you Board Certified?
Yes
No
Specialty?
Subspecialty?
Specialty Board Name                                                         Date Certified       Date Recertified                 Intending to Sit for Boards?
                                                                           Specify Date
Peer References:  List four (4) MD’s who can attest to your current clinical abilities, ethical
character and ability to work cooperatively with others. These should be individuals who will
provide written comments on these matters upon request.
1. Name                                        Telephone #                                2. Name                                        Telephone #
3. Name                                        Telephone #                                4. Name                                        Telephone #
Professional Memberships:  List professional memberships and societies, past and present.
Name of Society / Association                                                          Address                                                           Dates Affiliated
Have you been named in a malpractice claim?
Yes
No
If yes, how many?
Can you provide copies of initial complaint(s) and/or
the Settlement of Dismissal Page for each case?
Yes
No
Please list: any adverse actions taken by a medical school, hospital, licensing board, etc.; if you’ve ever been charged
with, or found guilty of a violation of any federal, state, or local statute; any unusual circumstances:
Thank you for completing our service application. We look forward to working with you.
I wish to obtain the services of Medical License Direct, LLC (MLD)
for the following state/s (please list priority order):
The fee for this service is:

•        $525 per state
•        $475 per state for 10 or more states at one time
We accept credit cards, checks and money orders
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We’ll be in touch soon to confirm that we received your application and payment.

Thank you again!
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Service Applications

We Offer Online or Paper Versions

Fill out our online form below, select payment and click "Submit." We've done our best to make this process as
effortless as possible for you. If you have any suggestions for improvement, please let us know. You may also fax
us a CV and we'll call or email you for any additional information. All our forms are SSL secure.

Or,
if you prefer, download and fill out our paper form (PDF format), print and fax, mail or email it to us. You
may substitute a CV for portions.

Thank you. We look forward to providing you with excellent customer service.
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