Affix a 2” by 2” photo here.
Photo must be recent and
must be of your head and
shoulder areas only.
Altered photos are NOT
acceptable.
PHOTOGRAPH AND NOTICE
MBC USE ONLY
Notice: All items in this application are mandatory.
Failure to provide any of
TF1-TF4
the requested information will delay the processing of your application.
information provided will be used to determine your qualifications for licensing
per Section 2080 of the California Business and Professions Code, which
authorizes the collection of this information. The information on your
application may be transferred to other medical licensing authorities, the
Federation of State Medical Boards, or other governmental law enforcement
agencies. You have the right to r
eview your application subject to the
provisions of the Information Practices Act.
Staff Initials
& Date
Photo
DECLARATION
DOB
Full Legal Name (First, Middle, Last, Suffix)
Date of Birth (mm/dd/yyyy
being first duly sworn upon his/her oath deposes and says: that I am the person herein named subscribing to this application;
that I have read the complete application, know the full content thereof, and declare under penalty of perjury, that all of
the
information contained herein and evidence or other credentials submitted herewith are true and correct; and that I am the
lawful holder of the degree of Doctor of Medicine as prescribed by this application, that the same was procured in the regula
co
urse of instruction and examination, and that it, together with all the credentials submitted, were procured without fraud or
misrepresentation or any mistake of which I am aware and that I am the lawful holder thereof. Further, I hereby authorize al
hos
pitals, institutions or organizations, my references, personal physicians, employers (past, present and future), or business
and professional associates (past, present, and future), and all government agencies (local, state, federal, or foreign) to
release
to the Medical Board of California or its successors any information, files or records, including medical records,
educational records, and records of psychiatric treatment and treatment for drug, alcohol and/or substance abuse or
dependency, requested b
y that Board in connection with this application; or any further or future investigation by that Board
necessary to determine any medical competence, professional conduct, or physical or mental ability to safely engage in the
practice of medicine. I furth
er authorize the Medical Board of California or its successors to release, in any investigation or
proceeding, to the organizations, individuals or groups listed above any information which is material to this application or
subsequent licensure.
I UND
ERSTAND THAT ANY OMISSION, FALSIFICATION, OR MISREPRESENTATION OF ANY ITEM OR RESPONSE ON
Applicant
Signature
THIS APPLICATION OR ANY ATTACHMENT HERETO IS A SUFFICIENT BASIS FOR DENYING OR REVOKING A LICENSE.
Applicant
Signature
(SIGN LEGAL NAME IN THE 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
, 20 ,
Print Applicant’s Legal Name
by,
proved to me on the basis of satisfactory evidence to be the person who
Applicant
Notary
Signature
& Seal
SIGNATURE OF NOTARY PUBLIC
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
