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
Verication of Postgraduate Training Form
Applicant’s name:______________________________________________________________________________
Hospital: _____________________________________________________________________________________
Hospital address: ______________________________________________________________________________
Street City State Zip Code Country
Hospital telephone number: _____________________________
Include area code
1. In what type and level(s) of training did this physician participate at your facility? Check each level in
which this physician participated. Provide starting and ending dates of training, type of training and
whether credit was awarded.
2. Was the residency/fellowship accredited by A.C.G.M.E. or A.O.A.? Yes No
3. Was the physician placed on probation, suspended or in any way sanctioned/disciplined or placed under
investigation while at your facility? Yes No
4. Was the physician granted a leave of absence or break from his/her training? Yes No
5. Were any restrictions placed on this physician’s activities that were not placed on all other residents/
fellows at his/her level of training? Yes No
6. Were any formal patient or staff complaints led against this physician? Yes No
7. Were any malpractice actions led naming this physician as a defendant that involved his/her period of
training at your facility? Yes No
If you answered “Yes” to any one of questions 3-7, please attach an explanation, and sign and date the
attachment. Also, please attach any additional comments or information that the Board should consider prior
to determining this applicant’s eligibility for licensure.
__________________________________________________________ _____________________________
Print Name of Program Director Date
__________________________________________________________
Signature of Program Director
Please return directly to: State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625-0183
BME-VPT-17
Hospital
Seal
If the hospital does not
have a seal, a letter
attesting to this fact,
on hospital stationary,
must accompany this
certicate.
PGY 1
PGY 2
PGY 3
PGY 4
Fellowship
Other
Dates
(Month/Year)
Specialty
Credit
None Partial Full
click to sign
signature
click to edit
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