Fillable License Application for a Physicians and Surgeons (California)

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License Application for a Physicians and Surgeons (California)

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The License Application for a Physicians and Surgeons (California) form is 6 pages long and contains:

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  • 6 check-boxes
  • 150 other fields

Country of origin: US
File type: PDF

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Medical Board of California
Application for a Physician’s and Surgeon’s
License
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
TYPE OF APPLICATION
(Check One)
U.S. or Canadian Medical Sch
ool Graduate International Medical School Graduate
App Type
(Check All That Apply)
Physician’s and Surgeon’s Certificate Limited Practice License Previously Licensed
PRIORITY REVIEW AND EXPEDITED LICENSURE
Honorably Discharged Veterans of the Armed Forces
Must supply satisfactory evidence to the Board that you have served as an active duty member of the Armed Forces of the
United States and were honorably discharged.
Priority
Practice in Medically Underserved Area or Population
Review
Must supply satisfactory evidence to the Board that you have accepted employment and intend to practice in an area of
California formally designated as an underserved area or underserved population. Please see further details on
the Board’s
website at http://www.mbc.ca.gov/Applicants/Physicians_and_Surgeons/Underserved.aspx.
Temporary License for Spouse of Active Duty Member of the Armed Forces
Must supply satisfactory evidence to the Board that you are married to, or in a domestic partnership or other legal union with, an
active duty member of the Armed Forces of the United States who is assigned to a duty station in California under official active
duty military orders. In addition, you must meet the requirements listed in Business and Professions Code section 115.6.
PERSONAL INFORMATION
Legal Name
Legal
Full Last Name
First Name
Middle Name
Suffix
Name
Other Names/Alias Date Of Birth
DOB
(mm/dd/yyyy)
Social Security Number or
Individual Taxpayer Identification Number
Gender
Female
Male
Telephone Numbers
(Include area code)
Primary
Cell
Work
Email Address
(Required)
SSN/ITITN
Gender
Phone
Email
Address Of Record
This address will be used for all current correspondence during the review process and will be posted on the Board’s
website upon issuance of a license. If you are using a P.O. Box, you are also required to list a confidential street address.
AOR
Line 1 (40 characters per line, including spaces)
Line 2 (40 characters per line, including spaces)
City
State/Province
Zip/Postal Code
Country
Confidential Address
Only required if Address of Record is a P.O. Box
Conf.
Line 1 (40 characters per line, including spaces)
Line 2 (40 characters per line, including spaces)
City
State/Province
Zip/Postal Code
Country
Address
1.
Are you a registered sex offender? Yes No
Sex
Offender
2.
Have you served or are you currently serving in the military?
3.
Are you requesting expediting of this application as a spouse or domestic partner of an
active duty member of the Armed Forces?
Yes
Yes
No
No
Military
MBC USE ONLY
Cashiering Modifier School Code
L1A
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
Applicant
Full Legal Name
Date of Birth
(mm/dd/yyyy)
PREVIOUS APPLICATION OR LICENSE
MBC USE ONLY
Name & DOB
A “yes” response to questions 4-5 requires a signed and dated written explanation. Use the Explanation For
Application Question (Form EXP) to provide your explanation.
Previous
4
.
Have you ever filed an application for a physician’s and surgeon’s license or other license
iApp/L cense
in California that has been withdrawn, abandoned, or denied?
Yes
No
5
.
Have you previously held a physician’s and surgeon’s license in California?
Yes
No
If yes, please provide license number: Expired:
EXAMINATIONS
ECFMG
6
.
Are you certified by the Educational Commission for Foreign Medical Graduates?
Yes
No
List all of the following examinations you have taken and passed. (USMLE, FLEX, NBME, LMCC and/or STATE
BOARDS)
Examination
Date Passed
(mm/dd/yyyy)
Exams
MEDICAL EDUCATION
To verify your medical school meets the requirements set forth in Business and Professions Code section 2084,
please use the links provided below.
Applicants must have received all of their medical school education from and graduated from: A U.S. or
Canadian medical school accredited by the Liaison Committee for Medical Education (LCME), the Committee
on Accreditation of Canadian Medical Schools, or the Commission on Osteopathic College Accreditation
(http://lcme.org/directory/accredited-u-s-programs/).
- OR -
An international medical school that has been evaluated by the Educational Commission for Foreign
Medical Graduates (ECFMG) or a foreign medical school listed on the World Federation for Medical
Education (WFME) and the Foundation for Advancement of International Medical Education and
Research (FAIMER) World Directory of Medical Schools joint directory or the World Directory of Medical
Schools (
https://search.wdoms.org/), or a foreign medical school that has been approved by the Board
(http://www.mbc.ca.gov/Applicants/Medical_Schools/Schools_Recognized.aspx).
List each medical school that you have attended and the medical school of graduation.
Medical
Medical School
Dates of Attendance
iEducat on
Name
Start Date (mm/dd/yyyy)
Mailing Address
End Date (mm/dd/yyyy)
MED
Trans
School Code
Name
Start Date (mm/dd/yyyy)
Mailing Address
End Date (mm/dd/yyyy)
MED
Trans
School Code
Medical School of Graduation Title of Degree Awarded Issue Date of Degree
(mm/dd/yyyy)
L1B
Diploma
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
Applicant
Full Legal Name
Date of Birth
(mm/dd/yyyy)
MBC USE ONLY
ACGME, RCPSC, or CFPC ACCREDITED POSTGRADUATE TRAINING PROGRAMS
Name & DOB
(Internship, Residency and Fellowship Programs)
PG Training
7.
Have you participated in any ACGME-accredited postgraduate training programs in the United
Programs
States, RCPSC or CFPC-accredited postgraduate training in Canada? Yes No
List every program (internship, residency and fellowship) in which you have participated or are currently
participating, regardless of whether the program was completed or any credit was granted.
Facility Specialty Dates of Training
Facility Name
Specialty
Start Date (mm/dd/yyyy)
City, State/Province
End Date (mm/dd/yyyy)
Faci
lity Name Specialty Start Date (mm/dd/yyyy)
City, State/Province End Date (mm/dd/yyyy)
Facility Name Specialty Start Date (mm/dd/yyyy)
City, State/Province End Date (mm/dd/yyyy)
A “yes” response to questions 8 – 14 requires a signed and dated written explanation. Use the Explanation
For Application Question (Form EXP) form to provide your explanation.
When in doubt as to whether a
postgraduate training issue should be disclosed, it is best to disclose the information on the application.
8.
Have you ever received partial or no credit for a postgraduate training program? Yes No
9.
Have you ever taken a leave of absence or break from your training? Yes No
10
.
Have you ever been terminated, dismissed, or expelled from a program? Yes No
11
.
Have you ever been placed on probation for any reason? Yes No
12
.
Have you ever been disciplined or placed under investigation? Yes No
13
.
Have you ever had any limitations or special requirements placed upon you for clinical
performance, professionalism, medical knowledge, discipline, or for any other reason?
Yes No
14
.
Have you ever had a postgraduate training program contract not be renewed or offered
for a following year? Yes No
MEDICAL LICENSE
15
.
Have you ever held or do you currently hold a medical license in any U.S. state, U.S.
License
territory, or Canadian province? Yes No
List medical license information for all licenses ever held below. Do not list temporary, training, or provisional
licenses. (If additional space is needed, please provide the required information on a separate sheet of paper).
U.S. State, U.S. Territory, or Canadian Province License Number Dates of Practice
(mm/dd/yyyy) (mm/dd/yyyy)
to
(mm/dd/yyyy) (mm/dd/yyyy)
to
(mm/
to
dd/yyyy) (mm/dd/yyyy)
(mm/dd/yyyy) (mm/dd/yyyy)
to
L1C
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
DISCIPLINARY HISTORY
These questions refer to discipline by any hospital, military or public health service, state board, or other
governmental agency of any U.S. state, U.S. territory, Canadian province, or foreign country. If in doubt as to
whether discipline should be disclosed, it is best to disclose the information on the application.
A “yes” response to question 18-26 requires a signed and dated written explanation. Use the Explanation For
Application Question (Form EXP) to provide your explanation.
18
.
Have you ever withdrawn an application for medical licensure in lieu of denial, disciplinary
action, or for any other similar reason?
Yes
No
Disciplinary
History
19.
Have you ever been denied
a license to practice medicine or is any denial pending against you?
Yes
No
20
.
Have you ever had any license to practice medicine subjected to any disciplinary action or
is any disciplinary action pending against any of your licenses to
practice medicine?
Yes
No
21.
Have you ever surrendered a license to practice medicine or have you ever had any license
to practice medicine revoked, suspended, or placed on probation?
Yes
No
22
.
Have you ever had any license to practice medicine subjected to any action including, but
not limited to, informal or confidential discipline, consent orders, letters of warning, letters
of reprimand, or citation?
Yes
No
23
.
Have you ever been charged with, or been found to have committed unprofessional
conduct, professional incompetence, gross negligence, or repeated negligent acts by any
medical licensing board or hospital?
Yes
No
24
.
Have you ever resigned from a medical staff in lieu of disciplinary or administrative action
or is any disciplinary action pending against your hospital or staff privileges?
Yes
No
25.
Have you ever had staff privileges in a hospital terminated, denied, suspended, limited,
revoked, or not renewed?
Yes
No
26
.
Have you ever had any healing arts license or certificate disciplined by another state or
federal territory?
Yes
No
Applicant
Full Legal Name
Date of Birth
(mm/dd/yyyy)
ABMS CERTIFICATION
MBC USE ONLY
Name & DOB
16
.
Are you currently certified by a Member Board of the American Board of Medical Specialties?
Yes
No
ABMS
MALPRACTICE HISTORY
A “yes” response to question 17 requires a signed and dated written explanation. Use the Explanation For
Application Question (Form EXP) to provide your explanation.
Malpractice
History
17
.
Has a claim or an action ever been filed against you for the practice of medicine that
resulted in a malpractice settlement, judgment, or arbitration?
Yes
No
L1D
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
Applicant
Full Legal Name
Date of Birth
(mm/dd/yyyy)
PRACTICE IMPAIRMENT OR LIMITATIONS
Please note that an affirmative answer to any of the questions below will not automatically disqualify you from
licensure. The Board will make an individualized assessment of the nature, the severity and the duration of the risks
associated with an ongoing medical condition to determine whether an unrestricted license should be issued,
whether conditions should be imposed, or whether you are eligible for licensure. Please note that a limited practice
license may be available. Refer to the application Information for a limited practice license for further information.
A “yes” response to question 27-29 requires a signed and dated written explanation. Use the Explanation For
Application Question (Form EXP) to provide your explanation.
Limitations
27.
Are you currently enrolled in, or participating in any drug, alcohol, or substance abuse
recovery program or impaired practitioner program?
Yes
No
28.
Do you currently have any condition (including, but not limited to emotional, mental,
neurological or other physical, addictive, or behavioral disorder) that impairs your ability to
practice medicine safely?
Yes
No
29.
Do you currently have any other condition that impairs or limits your ability to practice
medicine safely?
Yes
No
PROCEED TO FORM
L1F
L1E
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
PHOTOGRAPH AND NOTICE
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.
MBC USE ONLY
Notice: All items in this application are mandatory.
Failure to provide any of
Reviewed
L1A-L1F
the requested information will delay the processing of your application.
The
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
Applicant
Name & DOB
Full Legal Name (First, Middle, Last, Suffix)
Date of Birth (mm/dd/yyyy
The applicant,
,
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 procur
ed in the regular
course 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 here
by authorize all
hospitals, institutions or organizations, my references, personal physicians, employers (past, present and future), or busine
ss
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
dep
endency, requested by 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 o
f medicine. I further 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
any
subsequent licensure.
I UNDERSTAND 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.
& Date
SIGN LEGAL NAME:
DATE:
NOTARY SECTION
Applicant
Signature
SIGNATURE OF APPLICANT:
(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
day of
, 20 ,
Print Applicant’s Legal Name
by,
proved to me on the basis of satisfactory evidence to be the person who
appeared before me.
(NOTARY SEAL)
Applicant
Name &
Notary Date
Notary
Signature
& Seal
SIGNATURE OF NOTARY PUBLIC
L1F
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 06/20)
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License Application for a Physicians and Surgeons (California)

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Completed 27 December 2021

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