Uniform Application for Physician State Licensure Applicant _________________ _________________
September 2016 UA Affidavit and Authorization for Release of Information
Affidavit and Authorization for Release of Information
Applicant: In the presence of a notary public, sign this form with attached photo. If you are using FCVS for
credentials verification, consider having that form notarized at the same time. Send the separate notarized
FCVS form to FCVS. Do not send this form to FCVS as doing so will delay your licensure.
Send this form to the board you are applying to for licensure. For state medical and osteopathic boards,
refer to http://www.fsmb.org/policy/contacts for contact information. Include all other required materials.
To: Board name _________________________________________
Mailing address _________________________________________
I, the undersigned, being duly sworn, hereby certify under oath that I am the person named in this application, that all statements I have
made or shall make with respect thereto are true, that I am the original and lawful possessor of and person named in the various forms
and credentials furnished or to be furnished with respect to my application, and that all documents, forms, or copies thereof furnished or
to be furnished with respect to my application are strictly true in every aspect.
I acknowledge that I have read and understand the Uniform Application for Physician State Licensure and have answered all questions
contained in the application truthfully and completely. I further acknowledge that failure on my part to answer questions truthfully and
completely may lead to my being prosecuted under appropriate federal and state laws.
I authorize and request every person, hospital, clinic, government agency (local, state, federal, or foreign), court, association, institution,
or law enforcement agency having custody or control of any documents, records, and other information pertaining to me to furnish to
the Board any such information, including documents, records regarding charges or complaints filed against me, formal or informal,
pending or closed, or any other pertinent data, and to permit the Board or any of its agents or representatives to inspect and make
copies of such documents, records, and other information in connection with this application.
I hereby release, discharge, and exonerate the Board, its agents or representatives, and any person, hospital, clinic, government
agency (local, state, federal, or foreign), court, association, institution, or law enforcement agency having custody or control of any
documents, records, and other information pertaining to me of any and all liability of every nature and kind arising out of investigation
made by the Board.
I will immediately notify the Board in writing of any changes to the answers to any of the questions contained in this application if such a
change occurs at any time prior to a license to practice medicine being granted to me by the Board.
I understand my failure to answer questions contained in this application truthfully and completely may lead to denial, revocation, or
other disciplinary sanction of my license or permit to practice medicine.
State of _____________________, County of _____________________,
I certify that on the date set forth below, the individual named above did appear personally before me and that I did identify this
applicant by: (a) comparing his/her physical appearance with the photograph on the identifying document presented by the applicant
and with the photograph affixed hereto, and (b) comparing the applicant’s signature made in my presence on this form with the
signature on his/her identifying document.
The statements on this document are subscribed and sworn to before me by the applicant on this _____ day of ___________, 20____.
Notary Public Signature __________________________________________ My Notary Commission Expires _________________
Securely tape or glue a recent
(per the board’s instructions) front-
view 2” x 2” passport-type color
photo of yourself in this square.
Applicant’s signature (must be signed in the presence of a notary)
Applicant’s printed last name, first name, middle initial, and suffix (e.g., Jr.)
Date of signature (must correspond to date of notarization)
[Please note: The Notary Public seal should overlap the bottom of the photo to the left.]
WV Board of Osteopathic Medicine
405 Capitol Street, Suite 402