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 State License/Examination Form
I, __________________________________________________________________ , born ____________________
First Name Middle Initial Last Name Month / Day/ Year
*Social Security number _____ - _____ - ______ , hold/held medical license _____________________________
Registration Number
issued by ______________________________ . I am requesting that you complete this verication form and mail
State
it to State Board of Medical Examiners (address above) as per my authorization. Thank you.
I hereby authorize the State of ________________________________ to release all of the information in its les
concerning my license/exmnation and any actions or pending actions against my license to the State Board of
Medical Examiners.
______________________________________________ ___________________________
Signature Date
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey
Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8
and 60.9, the Board is required to obtain your Social Security number. Pursuant to these authorities, the
Board is also obligated to provide your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for
the purpose of reviewing compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request;
and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating
to health care professionals.
Section 2 - To be completed by the licensing/examination entity
The State of _______________________ certies that ____________________________________ was issued license
State Name of Physician
registration _____________________ . Date Issued __________________ Expiration Date __________________
License Number Month / Day / Year Month / Day / Year
The status of this license is currently: Active Inactive Other (specify) _________________
1. Is the license in good standing? Yes No
If “No,” please attach details and certied copies of any orders.
2. To your knowledge, has this physician ever been disciplined by your board or any other regulatory agency?
Yes No
If “Yes,” please attach details and certied copies of any orders.
3. Is there presently or has there been in the past a disciplinary proceeding against this licensee?
Yes No
If “Yes,” please attach details and certied copies of any orders.
4. Is there presently or has there been in the past an investigation conducted relative to this licensee?
Yes No
If “Yes,” please attach details and certied copies of any orders.
Please attach additional comments or information that the Board should consider prior to determining this
applicant’s eligibility for licensure.
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