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):
We accept credit cards, checks and money orders
The fee for this service is: • $545 per state for MDs and DOs or $525 per state if paid by check • $490 per state for MDs and DOs for ten (10) or more states at one time or $475 per state for ten (10) or more states at one time if paid by check
How did you find us?
After you click the "Submit" button you'll be taken to our Confirmation Page where you can download our service agreement and release. We’ll be in touch soon to confirm that we received your application and payment. Thank you again!