Form 4 - Verification Of Professional Practice Of Medicine In Another Jurisdiction
ADVERTISEMENT
1
2FOR ENDORSEMENT
FORM 4
The University of the State of New York
CANDIDATES ONLY
THE STATE EDUCATION DEPARTMENT
MEDICINE
Office of the Professions
OSTEOPATHIC LICENSES
Division of Professional Licensing Services
89 Washington Avenue
STATE MEDICAL LICENSES
Albany, NY 12234-1000
VERIFICATION OF PROFESSIONAL
PRACTICE OF MEDICINE IN ANOTHER JURISDICTION
APPLICANT INSTRUCTIONS
1. Complete Section I. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 6.
2. Forward this form to the endorser who will attest to your professional practice of medicine and request that he/she complete Section II and Section
III and return the form directly to the Office of the Professions at the address at the end of this form. Photocopy this form if you need additional
affiants to verify the total number of years of professional practice required for endorsement.
SECTION I: APPLICANT INFORMATION
1
BIRTH DATE:
2
SOCIAL SECURITY NUMBER:
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1):
Last
First
Middle
Apt./Bldg.
4
MAILING
ADDRESS:
Street
City
State
Zip Code
Province/Country
If not U.S.
5
Name of endorsing physician: ______________________________________________________________________________________________
If licensed in the United States, indicate state or territory: ________________________________________________________________________
6
I request and give my permission to the individual listed in item 5 above to complete Section II of this form and mail it to the New York State
Education Department and to release any other information required by the State Education Department in connection with my application for
licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
September 2002
FORM 4, PAGE 1 OF 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal