Applicant: Each school where physician assistant education was received must complete this form. If more than one school, photocopies
of this blank form may be made and used. Transcripts must also be submitted by the school(s).
FORM 1
NEVADA STATE BOARD OF MEDICAL EXAMINERS
PHYSICIAN ASSISTANT EDUCATION VERIFICATION
This certifies that
Printed Name of Applicant Date of Birth
was enrolled in
Name of Physician Assistant School (Location – City / State / Country)
The following information to be completed by program only!
The undersigned further certifies that the records of this institution show that the applicant attended this institution
From: To:
(Month/Year) (Month/Year)
The applicant was granted:
Physician Assistant Certificate
Physician Assistant Degree
Bachelor’s Degree
Combined Physician Assistant/Bachelor’s Degree
Combined Physician Assistant/Masters Degree
Other (Please attach explanation.)
The de
ree or certificate was
ranted:
(month / day / year)
Affix Seal Here
Signed and the institutional seal affixed this
day of ,
By:
Printed name of President, Registrar or Dean)
Title
Title of President, Registrar or Dean
Signature
Signature of President, Registrar or Dean **
Telephone:
Fax:
Email:
** Signatures by personnel other than the President, Registrar or Dean must attach documentation
granting authorization to sign in lieu of the President, Registrar or Dean.
Completed form is to be mailed by the verifying institution directly to:
Nevada State Board of Medical Examiners
9600 Gateway Drive
Reno, NV 89521
Physician Assistant School : If you have questions, you may contact the Board at (775) 688-2559. The Board requires that this verification
form be received by mail and NOT by facsimile.
