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IMPORTANT NOTICE!

ADDITIONAL APPLICATION

REQUIREMENTS

EFFECTIVE

FEBRUARY 1, 2003

Beginning February 1, 2003, applicants for licensure by this Board must provide certain additional information in order for the Board to conduct state and federal criminal history record checks. This information is in addition to all other information required by the license application and instructions.

Specifically, you are required to submit acceptable fingerprint cards and to complete the form entitled “Authority For Release of Information”. In addition, the application fee must include an additional fee to cover costs associated with the background check. Please look for the further details regarding these requirements in the application materials.

All applications received on or after February 1, 2003

must have this information.

GME

North Carolina Medical Board

Graduate Medical Education Training License “The practice of medicine is a privilege granted by the state.”

-from the Board’s Mission Statement

Dear Applicant:

A Graduate Medical Education (GME) training license may be issued to a physician, who is to participate in a recognized, fully accredited graduate medical program or an approved fellowship. Your completed application is to

be sent for credentialing to the GME Office of the institution you will be entering for postgraduate training. The GME Office will then forward the application to the North Carolina Medical Board (NCMB) for processing and review. Once the application is received by the Board’s Office, there is no guarantee a license will be issued by the start date. The processing of your application depends on many factors, including whether the Board requests additional information from the applicant or from other sources. The trainee must be licensed before beginning training. This requirement will not be waived.

The individual GME Office will coordinate the application process. Any questions you may have regarding your application are to be directed to the GME Office. Do not contact the NCMB. Due to the large volume of applicants seeking a GME training license, the NCMB will not be available to

talk with individual applicants and can only correspond with the GME Office.

To avoid delays in the processing of your application, please read all requirements and instructions very carefully.

North Carolina Medical Board

Requirements for Graduate Medical Education Training License

North Carolina General Statute 90-14 A (3) states an applicant may be denied or revoked if the applicant has made false statements or representations to the Board, or if the applicant has willfully concealed from the Board material information in connection with an application for a license.

The following materials must be submitted with your completed application to the Graduate Medical Education (GME) Office of the institution you are entering for postgraduate training as outlined by the Rules of Chapter 32 of the North Carolina Administrative Code. Some applicants may be required to meet additional requirements and/or meet with a representative of the Board prior to issuing a GME Training License. This will not be determined until your application has been reviewed by Board Staff. You will be notified through your GME Office if additional information is required.

It is highly recommended that you keep a personal copy of all the forms you complete in this application. Use each item below as a checklist to help guide you in completing the application.

1. Application Questionnaire, Chronological History, Claims Information, and Web site Oath Forms:

(A) Complete, sign, and notarize the Application Questionnaire Form, giving a detailed explanation for all

“Yes” answers as an addendum to your application. The addendum must be signed with your original

signature and dated. Note a “yes” answer to questions 12, 18, and 19 will also require completion of the

Claims Information, AMA/AOA Physician Profile, Federation Board Action Data Bank Inquiry, Medical

and Professional Licensure Biography, and Verification Forms.

(B) Complete the Chronological History Form starting with your high school and ending at the current date.

You must account for all time periods, as the Board will not accept any gaps in your history. A CV will

not replace having to complete this form.

Complaint and the Settlement Order, if a settlement was made.

(D) Sign and date the Web site Oath Form.

2. Criminal Background Check Instructions, Authority For Release of Information Form, Instruction

Sheet for Completing the Fingerprint Cards, and a Photocopy of a Sample Fingerprint Card:

(A) Two fingerprint cards are to be included with the residency documents sent to you by the GME Office. If

you did not receive these cards, please contact the GME Office of the institution where you will be

training for fingerprint cards. Do not contact the NCMB.

(B) Carefully read and follow the Criminal Background Check Instructions for the process of completing the

fingerprint cards at your nearest law enforcement agency. Use the Instruction Sheet For Completing the

Fingerprint Cards to complete each block on each of the actual fingerprint cards with the correct

information and in the proper format. Take the fingerprint cards and instructions with you to the law

enforcement agency. Photo identification and a fee may be required by the agency for performing the

fingerprinting.

(D) Return the two fingerprint cards and the Authority For Release of Information Form, along with your

completed application, to the GME office of the institution you are entering. Your application is not

considered complete without the fingerprint cards and the Authority for Release of Information Form and,

as such, your license will not be issued.

(E) Be aware that the NC Medical Board will reject fingerprints of poor quality and new prints will be

required. This will delay the processing of our application.

3. Medical Degree Certification Form (A) or (B):

(A) Complete Form (A) if you are a student who has completed the requirements for the MD or DO degree,

but has not received a medical degree. The majority of applicants will complete Form (A).

(B) Complete Form (B) if you have graduated and received your medical degree.

Do not use staples. The photograph should be a head and shoulder shot, no smaller than 2 ? x 3 ?

inches, taken within the past sixty (60) days, and of clear focus and durable quality (not a snapshot, home

Polaroid, or computer generated photograph). Where indicated on the MD Certification Form: print your

name, return address, and the name of the Graduate Medical Training Institution you are entering for

postgraduate training.

(D) Proof the MD Certification Form once it is returned to you before submitting it with your application to

the GME Office. This certification must bear the original signature of either the Dean or other Certifying

Official of your medical school; his/her official title; and a firmly imprinted and legible School Seal,

which has been affixed partially over your photograph as indicated on the form. These requirements

cannot be waived.

4. Transcripts:

(A) If you did not attend medical school in the usual four years, OR if you attended more than one medical

applicable.

(B) Please include a signed and dated letter explaining why you did not complete medical school in the usual

four years.

5. Two Current Physician Recommendation Forms:

(A) Read the instructions on the Physician Recommendation Form entitled “To the Applicant” very carefully

before submitting the form to physician members of your medical school faculty or to physicians at your

current location of medical practice. Be sure to print your name on both pages of the form.

(B) Advise the two recommending physicians that forms filled out incompletely or incorrectly will hold up

the processing of your application. The recommending physician cannot be a family member, an

extended family member, or spouse.

physician is to sign diagonally across the backside of the envelope using his/her original signature, not a

signature stamp. Do not open or break the seal of the envelope. The information contained within is

confidential. Return the sealed envelopes with your application to the GME Office.

6. Original Appointment Letter:

(A) The GME Office generally provides the appointment letter for you. The letter is addressed to the NC

Medical Board from the chief of service or the appointed representative in the department where you will

be receiving your training, and it should indicate the beginning date of the appointment. The letter must

bear an original signature. A copy of your contract will not be accepted.

(B) For Rotation Appointments ONLY: If the appointment is to complete a rotation in North Carolina as

part of a program you are enrolled in outside of North Carolina, submit a Rotation Appointment Form

from the chairman of the department at your current location, stating the rotation is part of an approved

6. (Cont’d) training program and it has been authorized. This form can be obtained from the North Carolina GME

Office where you will be rotating. In addition, you will need to submit a letter from the North Carolina

physician with whom you plan to be working. The letter must state that she/he has agreed to supervise

the rotation, give the beginning and ending dates of the rotation, and bear an original signature.

7. Fees:

(A) Make your Certified Check or Money Order payable to the North Carolina Medical Board in the

amount of $63.00. This amount includes a fee of $38.00 for the criminal history background check plus

the $25.00 licensure fee.

(B) Include your printed full name on the certified check or money order. Personal checks will not be

accepted.

Graduates Who Have Been Out of Medical School for Six (6) Months or More:

8. American Medical Association Physician Profile Form:

Medical Doctors and Doctors of Osteopathy, please submit this form directly to the AMA. The profile results will not be returned to you, but will be sent from the AM A to the NC Medical Board.

9. American Osteopathic Association Form:

Doctors of Osteopathy are to submit both the AMA Physician Profile Form and the American Osteopathic

Form. Please send each form to its respective institution. The AMA and AOA will mail the results directly to the NC Medical Board

10. Medical and Professional Licensure Biography Form:

If you hold or have held a medical license or any other professional license (i.e. lawyer, EMT, nurse, dentist, pharmacist, physical therapist, etc.), in the U.S., with the exception of a graduate training license, submit the Medical and Professional Licensure Biography Form for each medical/professional board in the state(s)

where you have held or hold a license (active or inactive).

11. Federation Board Action Data Bank Inquiry Form:

Submit this form directly to the Federation of State Medical Boards by either fax or mail. The inquiry results will not be returned to you, but will be sent from the Federation to the NC Medical Board.

For Graduates of Foreign Medical Schools ONLY:

12.Graduates of foreign medical schools must submit a photocopy of their current standard ECFMG

Certificate. If the expiration date on the certificate has expired, it will not be accepted and the processing of you application will be delayed. It is your responsibility to obtain a current certification.

Foreign graduates who completed a 5th Pathway Program must furnish verification of passing the ECFMG examination together with verification of completion of a 5th Pathway Program.

NORTH CAROLINA MEDICAL BOARD

GME TRAINING LICENSE APPLICATION QUESTIONNAIRE

University of North Carolina Hospitals

North Carolina General Statute 90-14 A (3) states an application may be denied or revoked if the applicant has made false statements or representations to the Board, or if the applicant has willfully concealed from the Board material information

in connection with an application for a license.

FULL LEGAL NAME (First/ Middle/ Last): _______________________________________________________________________________ OTHER NAMES YOU HAVE BEEN KNOWN BY (including maiden name): ____________________________________________________ PROVIDE COPIES OF OFFICIAL DOCUMENTS SHOWING NAME CHANGE (i.e. Marriage Certificate)

DATE OF BIRTH: (MONTH) __________ (DAY)__________ (YEAR) ___________ SOCIAL SECURITY #: __ __ __- __ __ - __ __ __ __ CITY OF BIRTH: ____________________________ STATE OF BIRTH: ___________ COUNTRY OF BIRTH: _______________________ NAME OF MEDICAL SCHOOL: ___________________________________________ MONTH/YEAR OF GRADUATION: _____________ LOCATION OF MEDICAL SCHOOL: (CITY)______________________________ (STATE) __________ (COUNTRY) _________________ PROGRAM SPECIALTY (i.e. Pediatrics, Family Practice, Internal Medicine, etc.): _________________________________________________ INDIVIDUALLY CIRCLE THE CORRECT ANSWER TO THE FOLLOWING QUESTIONS. IF ANY QUESTIONS ARE ANSWERED “YES”,

A DETAILED EXPLANATION MUST BE INCLUDED AS AN ADDENDUM TO YOUR APPLICATION.

1. Are you aware of any investigation, past or present, regarding you, which has been conducted by any governmental YES NO

agency or any professional licensing board?

2. Have you ever been convicted of or pled guilty to a violation of any federal, state, or local laws including traffic YES NO

violations? If “YES”, provide location (county and state), date of the occurrence, and violation.

3. Have you ever been denied a license or the privilege of taking an examination by any medical licensing board or YES NO

licensing agency?

4. Has a license of any type issued to you by any professional licensing board been revoked, suspended, had YES NO

probationary terms placed against it (limited or restricted), had other disciplinary action placed against it or been

issued through a public or private consent order?

5. Have you ever voluntarily or otherwise surrendered any license? YES NO

6. Have you ever been requested to appear before any medical board, disciplinary agency, military or federal agency,YES NO

medical society, or any other authorized representative of such organizations?

7. Have you ever been warned, censured, disciplined, had admissions monitored, had privileges limited, had privileges YES NO

suspended, been put on probation, or b een requested to withdraw from or failed to reapply for privileges, or been

denied staff membership by any licensed hospital, nursing home, clinic, managed care organization or other hospital

care facility with an organized medical staff, in which you h ave trained, been a staff member or held hospital privileges?

8. Have you ever been warned by the Drug Enforcement Administration (U.S. or State), or has any portion of your YES NO

controlled substance registration certificate voluntarily or otherwise, been limited, denied, revoked, suspended, or

surrendered?

9. Have you personally used or consumed in the past five (5) years any controlled substances or other prescription drugs YES NO

other than those lawfully prescribed for you?

10. Have you ever been told you are impaired as a result of your use of alcohol or other substances within the past YES NO

five (5) years?

11. Other than substance abuse, have you been told you are impaired as a result of your medical, surgical or psychiatric YES NO

condition within the past five (5) years?

12. Have you ever been a defendant in a legal action involving professional liability (malpractice); have you ever been YES NO

named in a malpractice suit, had a professional liability claim paid on your behalf or paid such a claim on

yourself? If “YES”, complete the Claims Information Form for ALL malpractice cases and provide a copy

of the Plaintiff’s Complaint and Settlement Order.

13. Have you ever had a professional liability policy canceled or not renewed? YES NO

14. Have you ever b een separated or discharged other than honorably from the U.S. military, foreign military, Veteran’s YES NO

Administration or Public Health Service?

15. Have you ever been suspended, place on scholastic or disciplinary probation, expelled or requested to resign from YES NO

any school, college, or university?

16. Are you aware of any reports made about you to the National Practitioner’s Data Bank? YES NO

17. Have you ever been associated with OR practiced OR held a license in any other medical or health related field? YES NO

(i.e. EMT, physician assistant, dentist, dental hygienist, nurse, nursing assistant, nursing aide, etc.)

18. Have you been out of medical school for more than six (6) months? If “YES”, a Physician’s Profile and a YES NO

Federation Board Action Data Bank Report must be obtained. Submit the enclosed forms to:

_____ American Medical Association and American Osteopathic Association, if applicable

_____ Federation of State Medical Boards

19. Have you ever held a state medical license (other than a training license), OR any other professional license,YES NO

OR have you ever been employed in a profession or occupation that did not require a license, but is under the aegis

of a certifying, governing, or disciplinary board, in any other state in the U.S.? If “YES”, list the state(s) and the

profession(s) on this application and use the enclosed M edical and Professional Licensure Biography Form to obtain

licensure verification (active or inactive) and/or the Verification Form to obtain verification of certification/membership

from all states and professions.

Profession/State(s): _____________________________________ Profession/State(s): __________________________________________ APPLICANT’S OATH

I hereby certify under oath that I am the person named in this application for a license to practice medicine in the State of North Carolina, that all statements I have made herein are true, and that I am the person named in the various forms and credentials furnished to this Board with my application. The photograph submitted as part of this application process is a true likeness of myself and was taken within a year prior to the date of this application.

I further state that by filing this application for a license to practice medicine in the State of North Carolina, I hereby authorize and consent to have an investigation made as to my moral character, professional reputation and fitness for the practice of medicine. I agree to give any further information, which may be required. I understand that I will not receive a copy of any report or know its contents, and I further understand that the contents of any investigative report will be confidential as provided by law.

I authorize and request every person, hospital, clinic community, governmental agency (local, state, federal, or foreign), court, association, institution, or other organization having control of any documents, records and other information pertaining to me to furnish to the North Carolina Medical 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.

I further permit the North Carolina Medical 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, subsequent licensure, or practice there under.

I hereby release, discharge and exonerate the North Carolina Medical Board, its agents or representatives and any person so furnishing information, from any and all liability for every nature and kind arising out of the furnishing or inspection of such documents, records, other information or the investigation made

by the North Carolina Medical Board.

Please read and sign the following statement in the presence of a Notary Public.

I affirm that all of the information, which I have provided, is correct to the best of my knowledge.

Applicant’s Signature: __________________________________________ Date: _________________________

Subscribed and sworn before me this ____________ day of ______________________________ 20______.

Notary Public: ________________________________________ State: _________________ County: ____________________ Commission Expires: __________________________________

(SEAL)

Use This Sheet as an Addendum to Your Application for Detailed Explanations to

“Affirmative Answers”

Please Write Legibly

Printed Name:____________________________________Date: ________________________________________ Signature:_____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

CHRONOLOGICAL HISTORY FORM

List in chronological order everything you have done starting with high school and ending at the current day. This includes the name of all high schools, colleges or universities, and medical schools attended; any graduate education received, as well as places of full and part-time employment. The NCMB requires you to account for all time and it will not accept any gaps in your chronology. The Board requires an explanation for all unemployed time (i.e. vacation, moving, etc.). Please give an explanation for any “leaves of absence” for medical reasons or otherwis e. A CV will not take the place of completing this form.

List the month and year, institution or place of employment, the geographical location, and FROM____________TO____________AT__________________________________________________ (mm/yyyy)(mm/yyyy)(Name of High School)

_____________________________________________________________________________________ (City/State/Country) (Position or Title)

FROM____________TO____________AT__________________________________________________

_____________________________________________________________________________________ FROM____________T O____________AT__________________________________________________

_____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________

_____________________________________________________________________________________

Printed Name: _________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________ FROM____________TO____________AT__________________________________________________ _____________________________________________________________________________________

NORTH CAROLINA MEDICAL BOARD

CLAIMS INFORMATION FORM

Please attach a photocopy of the Plaintiff’s Complaint

and the Settlement Order, if a settlement was made.

The applicant must complete this form for each liability or malpractice claim of which they are aware. Please make as many photocopies of this form as you need. Please use one form for each claim or suit.

1. Describe briefly the details of the allegations against you. Include the patient's name, a brief history, comments regarding the

examination and care surrounding the allegations. If suits are pending a very brief summary of the allegations or charges must be included regardless of the litigation stage. Simply stating that the charges were dismissed is inadequate. More detail must be provided.

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

2. Date of the claim: _____________________________________________________________________________________________

3. If an insurance carrier was involved, list the name, address and telephone: ___________________________________________

4. Plaintiff's Attorney & Telephone #: _____________________________________________________________________________

5. Is the claim pending? YES NO

6. Was there a judgment or settlement? YES NO

7. What was the amount and date of the judgment or settlement? ______________________________________________________

____________________________________________________________________________________________________________ 8. Comments: __________________________________________________________________________________________________

____________________________________________________________________________________________________________

I certify that the information, which I have provided, is correct to the best of my knowledge.

________________________________ _______________________ Signature Date

WEB SITE OATH

NORTH CAROLINA MEDICAL BOARD

P.O. Box 20007

Raleigh, NC 27619-0007

Toll Free in VA & NC (800) 253-9653

Applicants for a North Carolina medical license are required to complete this form and return it to the North Carolina Medical Board as part of their application for licensure.

I acknowledge it is my responsibility to be familiar with the North

Carolina Medical Practice Act and the North Carolina Medical Board’s Rules and Position Statements. These documents can be found on the Board’s Web site at https://www.doczj.com/doc/7c2953950.html,.

________________________________ _______________

Printed Name of Applicant Social Security No.

________________________________ _______________

Signature of Applicant Date

Criminal Background Check Instructions

For Graduate Medical Education Training License Effective February 1, 2003, pursuant to N.C. General Statute 90-11 (b) and Title 21 of the N.C. Administrative Code, Chapter 32B.0104, applicants for licensure by this Board must provide fingerprints as set forth in the above-referenced rule in order for the Board to conduct state and federal history record checks.

The Graduate Medical Education (GME) Training Institution you are entering will provide you with two actual fingerprint cards. The fingerprint cards should be included in the residency documents sent to you by the GME Office. If not, please contact the GME Office to obtain the fingerprint cards. Do not contact the NCMB.

Enclosed in the North Carolina GME training license application is a Photocopy of a Sample Fingerprint Card and Instruction Sheet for Completing the Fingerprint Cards. You must fill in the information on the actual fingerprint cards as indicated on the Sample. Follow the Instruction Sheet for Completing the Fingerprint Cards to ensure you are completing each block on the actual fingerprint cards with the correct information and in the correct format. Be aware that the law enforcement agency may require photo identification and a fee for performing the fingerprinting. Fingerprints of poor quality will be rejected, and new prints will be required. If this occurs there will be a delay in the processing of your application. Your application is not considered complete without the two fingerprint cards and, as such, your license will not be issued. When you have completed your GME training license application, please return it to the Graduate Medical Education Office where you will be training, along with the two properly completed fingerprint cards, the completed Authority For Release of Information Form, and a certified check or money order made payable to the NC Medical Board in the amount of $63.00.

AUTHORITY FOR RELEASE OF INFORMATION

State and Federal Record Check

I authorize the North Carolina Department of Justice through the State Bureau of Investigation, Division of Support Services to perform a fingerprint search of the State’s criminal history record file and a fingerprint search of the Federal Bureau of Investigation’s files for a national criminal history record check in connection with my application for a medical license with the North Carolina Medical Board pursuant to N.C.G.S. 90-11(HB 1638).

(Print or Type)

Last Name First Middle Maiden

___________________ _______________ _____________ __________

Social Security Number Date of Birth Sex Race

___________________ ___________ ____ ____

I understand that th e North Carolina State Bureau of Investigation, Division of Support Services, and its officials and employees shall not be held legally accountable in any way for providing this information to the North Carolina Medical Board, and I hereby release said age ncy and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the North Carolina Medical Board cannot provide a hard copy of the results of this criminal history record check to me.

Applicant’s Signature

_______________________________

Date

______________

ORI # BOME00000 – NORTH CAROLINA MEDICAL BOARD

01-132-10

North Carolina Medical Board

November 2002

Instruction Sheet for Completing the Fingerprint Cards

1. The complete name of the subject is to be listed as indicated: Last name, First name, and Middle name. Please ensure

the name is legible if written.

2. Signature of the subject being fingerprinted is written here.

3. List any and all alias names or nicknames, maiden name or any other married names.

4. List the date of birth numerically – month, day, and year.

Example: May 11, 1948, should be shown as 05111948; October 15, 1930, should be shown as 10151930

5. Current residence of subject fingerprinted is written here.

6. Sex is to be listed M for male, and F for female, or U for Unknown.

7. Race is to be listed by placing an individual into one (1) of the following categories by writing the appropriate letter in

the space provided:

W - White

B - Black

I - American Indian or Alaskan Native

A - Asian or Pacific Islander

U - Unknown if unsure or unable to determine

8. Indicate the subject’s height in feet and inches using all numerics.

Example: 6’01” = 601, 6’11” = 611, 6’ = 600

9. Indicate the subject’s weight in pounds using all numerics.

Example: 186 or 098, etc.

10. List the subject’s eye color by placing one (1) of the following eye color codes in the space provided:

BLK – Black GRY – Gray MAR – Maroon

BLU – Blue GRN – Green PNK – Pink

BRO – Brown HAZ – Hazel XXX – Unknown

11. Color of hair should be indicated by writing one (1) of the following color codes in the space provided:

BAL – Bald (When subject has lost most of his hair or is hairless)

BLK – Black

BLN – Blond or Strawberry

BRO – Brown

GRY – Gray or partially

RED – Red or Auburn

SDY – Sandy

12. Indicate, if possible, the city and state where the subject was born. The state should be indicated by the two-digit

abbreviation.

13. Indicate the date of the fingerprinting here.

14. Signature of Official taking fingerprints is written here.

15. Write the Social Security number in this space. The Social Security number is a very important identifier.

North Carolina Medical Board

Medical School Certification Form (A)

Form (A) is to be completed by fourth year medical students who have completed the requirements for the MD/DO degree, but have not received the degree.

DO NOT ALTER THIS FORM!

Applicant to Print Full Name: ________________________________________________ To: NCMB Executive Director and _____________________________________________

(Name of Graduate Medical E ducation Training Institution)

My signature certifies that this is a true likeness of _________________________________ who has completed the requirements for the MD or DO degree and is anticipated to receive the MD or DO degree from the _________________________________________________ (School of Medicine) on the _________day of __________________ in the year of 20_____.

“Original” Signature of Certifying Official:

Signature Stamps Not Acceptable

Printed Name of Certifying Official:

_________________________________

Title: ____________________________

Date: ____________________________

Address of Medical School:

_________________________________

Phone Number of Medical School:

_________________________________

Attention Certifying Official:

Please return this fo rm to the Applicant for

inclusion in his or her application at: School Seal must be legible!

_________________________________ Medical School to Affix School

Seal Partially Over Photograph

_________________________________

North Carolina Medical Board

Medical School Certification Form (B)

Form (B) is to be completed by physicians who have graduated

and received a medical degree.

DO NOT ALTER THIS FORM!

Applicant to Print Full Name: ________________________________________________

To: NCMB Executive Director and ______________________________________________

(Name of Graduate Medical E ducation Training Institution)

My signature certifies that this is a true likeness of _________________________________ who received the MD or DO degree from the _____________________________________ (School of Medicine) on the _________day of __________________ in the year of _______.

“Original” Signature of Certifying Official:

Signature Stamps Not Acceptable

Printed Name of Certifying Official:

_________________________________

Title: ____________________________

Date: ____________________________

Address of Medical School:

_________________________________

Phone Number of Medical School:

_________________________________

Attention Certifying Official:

Please return this form to the Applicant for

inclusion in his or her application at: School Seal must be legible!

_________________________________ Medical School to Affix School

Seal Partially Over Photograph

_________________________________

Physician Recommendation Form

For Graduate Medical Education Training License Applicants

North Carolina Medical Board

PO Box 20007

Raleigh, NC 27619-0007

Applicant’s Printed Full Name: ______________________________________________________________ To the Applicant:

This form must be sent from the recommending physician directly to you in a sealed envelope. The recommending physician is to sign diagonally across the seal on the backside of the envelope using her or his original signature, not a signature stamp. Do not open or break the seal of the envelope.

This form must meet the following criteria:

1) Recent, no older than six months.

2) Bear the original signature of the recommending physician.

3) Two Physician Recommendation Forms are required and the physician must be either a DO or MD,

forms completed by PhD’s are not acceptable.

a) One recommendation should be from a physician who is currently observing your medical

skills.

b) If you are still a medical school student, it is preferable that the Dean of your medical school

completes the second recommendation.

c) If you are or have been a resident at another institution, it is preferable that the Program

Director from the institution you are coming from completes the second recommendation.

To the Recommending Physician:

On the application form, the applicant has agreed to release, discharge, and exonerate any person furnishing information from any and all liability of every nature and kind arising out of this furnishing or inspection of documents, records, other information or the investigation made by the North Carolina Medical Board. Your response is confidential, pursuant to North Carolina law.

*Please complete all thirteen questions on this form, date and sign the form with your original signature, and return it to the applicant in an envelope signed (your original signature only) diagonally across the back seal (flap).

Be aware that the processing time for licensure depends on the timely receipt of critical forms such as this. We ask you to fill the form out completely and print legibly to prevent delays for the applicant.

_________________________________________________________________________________________ Full Name of Recommending Physician (Indicate MD or DO)

_________________________________________________________________________________________

Address (Street, City, State, Zip Code)

_________________________________________________________________________________________ Area Code/Phone Number E-mail Address

1) How long have you known the applicant? _____________________________________________________

2) What is your relationship to the applicant? ____________________________________________________

Please circle the correct answers to the questions on the following page.

Applicant’s Printed Full Name: ______________________________________________________________ Questions 3 through 9 require an explanation for “YES” answers.

3) Have you ever received reports of poor medical practice by this

student/physician or have you discussed concerns about her/his

practice with medical staff officers at a hospital? Yes No N/A 4) Have you ever received reports of poor relationships between this

student/physician and other members of hospital medical staff? Yes No N/A 5) Are you aware of any derogatory information about this

student/physician with respect to her/his ability to practice medicine? Yes No N/A 6) Does this student/physician have or has this student/physician had in

the past, any mental or physical illnesses or personal problems that

interfere with her/his medical practice? Yes No N/A 7) Has this student/physician ever abused alcohol or drugs or shown

signs of chemical dependency? Yes No N/A 8) Are you aware of any lawsuits having to do with this

student’s/physician’s medical practice that this student/physician has

either lost or settled out of court? Yes No N/A 9) Are you aware of any restrictions, limitations or other actions of any

nature taken against this student/physician by a hospital or other

health related entity? Yes No N/A Questions 10 through 13 require an explanation for “NO” answers.

10) Does this student/physician accept medical staff and hospital policies

and function willingly according to these policies? Yes No N/A 11) Does this student/physician enjoy professional respect among her or

his colleagues and in the community where this student/physician

practices?Yes No N/A

12) Are you sorry to see this student/physician leave your community? Yes No N/A

13) Do you recommend this student/physician for resident training

licensure in North Carolina? Yes No N/A Comments: ______________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

_________________________________________________________________________________________ Signature (Indicate MD or DO)Title

______________________________________________________________________________________________________ Name of Hospital (If applicable)Current Date Required