Form 08-4004a - Verification Of Paramedic Internship Training printable pdf download

Form 08-4004a - Verification Of Paramedic Internship Training

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMERCE AND ECONOMIC DEVELOPMENT

DATE

DIVISION OF OCCUPATIONAL LICENSING

STATE MEDICAL BOARD

P.O. BOX 110806

JUNEAU, ALASKA 99811-0806

(907) 465-2541

E-Mail: License@commerce.state.ak.us

VERIFICATION OF PARAMEDIC INTERNSHIP TRAINING

Paramedic’s Name:

Address:

Dear Dr.

I am applying for licensure as a Mobile Intensive Care Paramedic in the State of Alaska. It is a requirement that the information

below be completed and notarized by the physician who was responsible for supervision during my paramedic internship training.

Please complete this form and return it directly to the address above. Thank you for your assistance.

Signature of Paramedic/Applicant

PARAMEDIC INTERNSHIP (See reverse)

I hereby certify that

was under my supervision during his/her paramedic

internship in

(location), from

and that I further certify that she/he successfully completed the

internship requirements per 12 AAC 40.310(5) and 12 AAC 40.325 (see reverse side) and she/he is capable of performing the

activities listed in 12 AAC 40.370(a). I recommend him/her for licensure as a mobile intensive care paramedic.

Print Name (Supervising Physician)

Signature (Supervising Physician)

States in which licensed and license number:

SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of

this

day of

NOTARY SEAL

Notary Public

My Commission Expires:

08-4004a (Rev. 12/97)

Form 08-4004a - Verification Of Paramedic Internship Training