Fillable Certificate of Completion of ACGME/RCPSC/CFPC Po stgraduate Training (California)

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Certificate of Completion of ACGME/RCPSC/CFPC Po stgraduate Training (California)

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Medical Board of California
Certificate of Completion of
ACGME/RCPSC/CFPC Po
stgraduate Training
Licensing Program
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815-
5401
Phone: (916) 263-
2382
Fax: (916) 263-
2487
www.mbc.ca.gov
MBC USE ONLY
APPLICANT INFORMATION
Applicant
Information
Check One: U.S. or Canadian Medical School Graduate International Medical School Graduate
Legal Name
Full Last Name
First Name
Middle Name
Suffix
Date Of Birth
(mm/dd/yyyy)
U.S. SSN or ITIN
(Last 4 digits)
Medical School of Graduation
PROGRAM DIRECTOR TO COMPLETE ACGME, RCPSC, or CFPC TRAINING INFORMATION
Facility
Name
Facility
Address
Verified
Program
Information
Specialty
Required
ACGME 10-digit Program#
https://apps.acgme.org/ads/Public
Required
Dates of Training
Start Date (mm/dd/yyyy)
End Date (or anticipated completion date): (mm/dd/yyyy)
UNUSUAL CIRCUMSTANCES
Program Director: Provide a signed and dated letter of explanation, including dates, for any “yes” response to questions
# 1-7. The explanation must be provided on program letterhead and mailed directly to the Board with this form.
1.
Did the applicant receive partial or no credit during postgraduate training? Yes No
2.
Did the applicant ever take a leave of absence or break from training? Yes No
3.
Was the applicant ever terminated, dismissed, or expelled? Yes No
4.
Was the applicant ever placed on probation? Yes No
5.
Was the applicant ever disciplined or placed under investigation? Yes No
6.
Were any limitations or special requirements placed upon the applicant for clinical
performance, professionalism, medical knowledge, discipline, or for any other reason?
Yes No
7.
Did the program decline to renew or offer the applicant postgraduate training program
contract for a following year?
Yes No
GENERAL MEDICINE TRAINING REQUIREMENT
Applicants must complete and receive credit for at least four (4) months of general medicine as part of their
postgraduate training. The GENERAL MEDICINE requirement may be satisfied by actual clinical practice where the
applicant had direct patient care responsibilities for at least four months in any particular specialty or sub-specialty area.
8.
Did the applicant complete and received credit for a minimum of four months of general
medicine as part of this postgraduate training program accredited by the ACGME or the
RCPSC?
Yes No
Gen Med
Required
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 12/19)
APPLICANT INFORMATION
MBC USE
ONLY
Applicant
Name
Legal Name
Full Last Name
First Name
Middle Name
Suffix
ATTENTION: PROGRAM DIRECTOR
Do not sign and date this form prior to the last day of any postgraduate training year which will be used by the applicant
to qualify for licensure. Completion of this form will certify that the applicant has satisfactorily completed a period of
accredited postgraduate training at this facility and that the applicant has acquired the skill and qualifications
necessary to safely assume the unrestricted practice of medicine in this state.
Only the program director may sign this form. If that signature authority is being delegated to another person, evidence
of that delegation must be attached to this form (may be a photocopy). Such delegation must be on official letterhead
and must be dated within the last 12 months. The person who signs this form may not be related to the applicant by
blood, marriage, or adoption.
PROGRAM DIRECTOR OFFICIAL CERTIFICATION
The program director signing this form is formally certifying and documenting under penalty of perjury that the applicant
received instruction appropriate for the particular postgraduate level and that the applicant satisfactorily completed
periods of training in accordance with the accepted standards and the criteria defined as equating to satisfactory
performance. The program director is attesting to the fact that the applicant has acquired the skill and qualifications
necessary to safely assume the unrestricted practice of medicine in this state.
I hereby declare under penalty of perjury under the laws of the State of California that all of the information contained on these forms is true
and correct. I further certify that the training program is accredited by the ACGME, RCPSC, or CFPC to offer the type and level of training
completed by the applicant named on this form, and the applicant was trained in an ACGME, RCPSC, or CFPC slotted program position.
Verified
PD
Staff
Initials &
Date
PRINTED NAME OF PROGRAM DIRECTOR
SIGNATURE OF PROGRAM DIRECTOR
DATE
Program
Director’s
Signature &
Date
Note: If a program seal is not available, the program director shall also sign in the section below in the presence of a
notary public.
Program
Director’s
SIGNATURE OF PROGRAM DIRECTOR:
Signature
(SIGN FULL NAME IN PRESENCE OF NOTARY)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which
this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of
County of
Subscribed and sworn to (or affirmed) before me on this
day
of
, 20
,
Print Program Director’s Name
by,
Notary
Signature
& Seal
Program
Seal
proved to me on the basis of satisfactory evidence to be the person
who appeared before me.
SIGNATURE OF NOTARY PUBLIC
(PROGRAM or NOTARY SEAL)
Note: The completed forms must be submitted directly from the program to the Board to be acceptable.
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 12/19)
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Certificate of Completion of ACGMERCPSCCFPC Po stgraduate Training (California)

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Completed 27 December 2021

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