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Form Med - Acceptance Of Responsibility By Alaska Facility, Hospital, Clinic - Alaska Department Of Community And Economic Development

ALASKA STATE MEDICAL BOARD

MED

Department of Community and Economic Development

For Office Use Only

Division of Occupational Licensing

(333 Willoughby Avenue - Ninth Floor)

Post Office Box 110806, Juneau Alaska 99811-0806

(907) 465-2541

E-Mail: license@dced.state.ak.us

ACCEPTANCE OF RESPONSIBILITY

ALASKA FACILITY, HOSPITAL, CLINIC

Instructions to the Resident Applicant:

Complete the information in Parts I and II below. Type or print legibly. Mail the

form to the Alaska facility, hospital, or clinic where you intend to serve your

residency rotation.

PART I

RESIDENT APPLICANT

Name:

Last, First, Middle (Maiden or Other Names Used)

Date of Birth (M/D/Yr)

PART II

RESIDENCY PROGRAM

Name of Program

Address

Program Telephone

City, State, Zip

(Applicant: Do Not Write Below This Line. Do Not Detach.)

Instructions to the Alaska Facility:

Please complete Part III below, sign Part IV, and return this document directly to the

board at the letterhead address.

PART III

ROTATION AUTHORIZED FOR

Name of Alaska Facility, Hospital, Clinic

Location

Dates of Rotation:

From:

To:

Physician Primarily

Responsible for

Printed

Training/Supervision:

Name ________________________________

Signature _________________________________ Date____________

PART IV

VERTIFICATION OF ACCEPTANCE OF RESPONSIBILITY

I CERTIFY THAT the Resident Physician named above has been accepted by this institution to serve as a resident. This

physician will be serving a portion of his/her clinical training at the Alaska institution named above. This institution accepts

responsibility for this physician’s training and supervision while he/she is located at this institution.

_________________________________________________________

________________________________________________________

Signature, Physician Clinical Director

Date

Printed Name

Title

08-4022 d (Rev 09/2000)

ALASKA STATE MEDICAL BOARD

MED

Form Med - Acceptance Of Responsibility By Alaska Facility, Hospital, Clinic - Alaska Department Of Community And Economic Development

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