Fillable Timeline of Activities (California)

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Timeline of Activities (California)

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Medical Board of California
Timeline of Activities
Licensing Program
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815-5401
Phone: (916) 263-2382
Fax: (916) 263-2487
www.mbc.ca.gov
APPLICANT INFORMATION
Legal Name
Full Last Name
First Name
Middle Name
Suffix
Date of Birth
(mm/dd/yyyy)
U.S. SSN or ITIN
(Last 4 digits)
Medical School of Graduation
TIMELINE OF ACTIVITIES
A complete timeline of activities from graduation of medical school to present is required. Provide a written
M
chronological description of all your professional and non-professional activities. Include a detailed description of
your duties and responsibilities for any externship, observership, or volunteer activity in California. Dates shall be
reported in chronological order in month/year (mm/yyyy) format.
Location (Facility Name, Address, and Supervisor)
BC USE ONLY
Start Date
Activities
End Date
Location (Facility Name, Address, and Supervisor)
Start Date
Activities
End Date
Location (Facility Name, Address, and Supervisor)
Start Date
Activities
End Date
Location (Facility Name, Address, and Supervisor)
Start Date
Activities
End Date
SIGN LEGAL NAME:
DATE:
Applicant’s signature and date are required
Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 12/19)
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Timeline of Activities (California)

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Completed 27 December 2021

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