New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Medical Education Verication Form
Applicant’s name:______________________________________________________________________________
Medical school: _______________________________________________________________________________
Medical school address: ________________________________________________________________________
Street City State Zip Code Country
Telephone number: _____________________________
Include area code
1. Did this physician attend the medical school noted above? Yes No
2. What were the applicant’s dates of enrollment? ____________ to ___________
Month/Year Month/Year
3. Did this physician graduate from this medical school? Yes No
If “No,” please explain below:
__________________________________________________________________________________________
__________________________________________________________________________________________
4. What was the date of graduation? ______________
Month/Year
5. Did this individual take a leave of absence during his/her attendance at this medical school?
Yes No
If “Yes,” what was the reason for the leave of absence?
__________________________________________________________________________________________
__________________________________________________________________________________________
6. Was this individual on probation during his/her attendance at this medical school? Yes No
7. Was this individual ever disciplined or under investigation during his/her attendance at this school?
Yes No
8. Were any negative reports led by instructors regarding this individual? Yes No
9. Were any special requirements imposed on this individual that were not required of all other students at
his/her level of education? Yes No
Please supply any additional comments or information that the Board should consider prior to determining
this applicant’s eligibility for licensure.
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________ _____________________________
Print Name of Registar Date
__________________________________________________________
Signature of Registar
Please return with an ofcial transcript directly to: State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625-0183
BME-MEV-17
Seal of
Medical
School
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signature
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