T:\Licensing\New License Applications and forms\New License Application\MD Initial Teaching Application. Revised 03.19.2018
Note: In the event the response to any of the questions numbered 10 through 26 is "YES", the applicant must file with the application a
detailed report concerning the above matters, including any charge, date of such charge, the complete name and address of all bodies
of jurisdiction, the result of any hearings, and the disposition of such charge(s). IN ADDITION, the applicant must submit photocopies
of any complaints, hearings, settlements or judgments together with copies of patient's hospital and/or office records to the AMB.
Moral Turpitude includes but is not limited to the following: Armed Robbery, Assault with a Deadly Weapon, Attempted Insurance Fraud,
Fabricating and Presenting False Public Claim, False Reporting to Law Enforcement Agency, Falsification of Records of the Court, Forgery,
Fraud, Hit & Run, Illegal Sale & Trafficking in Controlled Substances, Indecent Exposure, Kidnapping, Larceny, Mann Act (Federal
Commercialization of Women Statute), Misleading Sale of Securities in Connection with Transfer of Real Property, Perjury, Possession of
Heroin for Sale/Unlawful Sale or Dispensing Narcotic Drugs, Rape, Shoplifting and Soliciting Prostitution.
1. Have you ever had any application for any professional license refused or denied by any licensing
2. Have you ever been refused or denied the privilege of taking an examination required for any
3. Have you ever been dropped, suspended, placed on probation, expelled, fined, resigned or been
requested to resign from any medical school or post secondary educational program in which you were
4. Has any training program taken action against you including probation, restriction, suspension,
revocation, modification, accepted resignation, asked you to leave temporarily or permanently?
5. Have you ever voluntarily surrendered any healthcare license?
6. Have you ever had any healthcare license revoked?
7. Have you ever been the subject of disciplinary action or are you currently under investigation with
regard to your healthcare license, been sanctioned by any healthcare licensing authority, healthcare
association, licensed healthcare facility or healthcare staff of such facility?
8. Have your privileges ever been restricted, terminated, voluntarily or involuntarily resigned or
withdrawn by any healthcare licensing authority, healthcare association, licensed healthcare facility or
healthcare staff of such facility?
9. Has disciplinary action been taken against you by any licensing agency with regard to any
professional license? Including but not limited to restricted, terminated, voluntarily or involuntarily
resigned or withdrawn.
10. Are there any pending complaints, investigations, or disciplinary actions against you with any
healthcare licensing authority, healthcare association, licensed healthcare facility or healthcare staff of
11. Have you ever had a registration issued by a controlled substance authority (State or Federal)
revoked, suspended, limited, restricted, modified, denied or have you surrendered or given up in lieu of
12. Have you ever been charged with or convicted, pardoned or had a record expunged or vacated of a
felony, misdemeanor involving moral turpitude? (see explanation below)
A "yes" answer is required even if you entered a diversion program.
13. Have you ever been charged with or convicted (including a nolo contendere plea or guilty plea) of a
violation of any federal or state drug law(s) or rule(s) whether or not sentence was imposed or
14. In the last ten (10) years has a judgment or settlement been entered against you as a defendant in a
medical malpractice suit? *Please DO NOT report pending malpractice suits or settlements paid not
related to a civil action.
15. Have you ever been court martialed or discharged other than honorably from the armed service?
16. Have you ever been terminated from a healthcare position with a city, county, or state government or
the Federal government?
17. Have you ever been convicted of insurance fraud or received sanctions, including restrictions,
suspension or removal from practice, imposed by any agency of the Federal government?
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