T:\Licensing\New License Applications and forms\Misc Applications\Postgraduate Training Applications\Revised 2018\03.19.2018
ARIZONA MEDICAL BOARD
POSTGRADUATE TRAINING PERMIT REGISTRATION
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Citizenship Statement
This form is to be completed by the applicant and is to be submitted for every application, permit or registration that is offered by the Arizona Medical Board, with the
exception of the renewal of license if citizenship has previously been established with the Board.
Evidence List
Provide proof of lawful presence in the United States in accordance with A.R.S. § 41-1080 (See Evidence List- as referenced for miscellaneous license application types at
www.AZMD.GOV/Physician Center/New Arizona License.).
Check this box if this is a renewal for a current Post Graduate Training Permit.
The Board shall grant a one year renewable training permit to a person participating in a teaching hospital's accredited internship, residency or clinical
fellowship training program to allow that person to function only in the supervised setting of that program. If a person who is participating in a teaching
hospital's accredited internship, residency or clinical fellowship program must repeat or make up time in the program due to resident progression or other
issues, the Board may grant that person a training permit if requested to do so by the program's director of medical education or a person who holds an
equivalent position. The individual must register with the Board for each year of training and pay the statutory nonrefundable $50.00 registration fee.
The following information must be completed by the applicant and the licensed hospital which sponsors the accredited training program. This form also
applies to applicants applying for a short-term training permit of four months or less. Please submit the registration to the Arizona Medical Board, 1740 W.
Adams Street. Suite. 4000, Phoenix, AZ 85007 at least thirty (30) days prior to the initiation of the training.
Mobile Phone:
Home Phone:
Email:
Zip:State:City:
Current Home Address:
Last Name:Initial:First Name:
Social Security Number:
Date of Birth (Month, Day, Year):
County:State:Birth City:
Permit # R
Expiration Date:
PROGRAM TO COMPLETE BELOW:
Internship
Residency
Fellowship
Type of Program:
Name of Facility:
(Arizona ACGME Approved Hospital or University Name)
(i.e. Internal Medicine, Gastroenterology, Psychiatry, Family Medicine, etc….)
Specialty Field:
Permit Dates requested:
From (m/dd/yr)
To (m/dd/yy):
I hereby certify I am authorized to request a postgraduate training permit for the above named facility.
Signature:
Title:
Name (Printed):
Date:
Phone Number:
Arizona Medical Board:
Permit Issued Date:
_________________
_________________
Permit Number:
Not to exceed one year
Please indicate if you would like to designate/authorize ONE other individual beside yourself to receive status updates on your application
Name:
Phone#
Email:
1740 W. Adams St. Suite. 4000, Phoenix, AZ 85007-2664
(Internship-Residency-Fellowship)
