Medical Board of California
Licensing Program
2005 Evergreen Street, Suite 1200
Certificate of Medical Education
Sacramento, CA 95815-
Phone: (916) 263-
Fax: (916) 263-
TYPE OF APPLICATION
U.S. or Canadian Medical School Graduate International Medical School Graduate
Applicant
APPLICANT INFORMATION
Applicant
Information
Medical School of Graduation
MEDICAL SCHOOL: PLEASE COMPLETE THIS FORM IN THE ENGLISH LANGUAGE
Note: If the applicant had an accelerated or extended curriculum, withdrew from this institution, or was accepted with
Medical
advanced standing, a letter of explanation from a school official is required. The letter must be on medical school
School
Information
letterhead, signed by a school official, and mailed directly to the Board from the medical school.
Code:
Rev. MED
Staff Initials &
Date:
Did the applicant withdraw or transfer from this medical school? Yes No
What is the standard duration of the curriculum at this institution?
years
the applicant was enrolled in medical school:
Date the applicant was issued the diploma of Bachelor/Doctor of
Medicine:
MEDICAL SCHOOL OFFICIAL CERTIFICATION
Attention Medical School: Only the President, Dean, or Registrar may sign this form. If the signature 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.
AFFIX MEDICAL SCHOOL SEAL
I certify that I am the President, Dean, or Registrar and hereby declare under penalty of perjury
School Seal
under the laws of the State of California that the above statements are true and correct.
PRINTED NAME OF SCHOOL OFFICIAL
Date
SIGNATURE OF SCHOOL OFFICIAL
Note: The completed form must be submitted directly from the medical school 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)
