MedLicense Order Form

MedLicense.com

Professional Medical Licensure in all 50 States

770.456.5932 info@medlicense.com

States where you want to obtain a Medical License: *

If you were directed by a company to apply through MedLicense.com - please enter the name of the company here

Are you currently Active Military?

NO - Not Active Military

YES - Active Military

Are you CURRENTLY completing an Internship, Residency, or Fellowship?

Yes

Full Legal Name (on Identity Documents and Medical School Diploma): *

Mailing Address: *

Phone Number: *

Email: *

Date of Birth: *

Place of Birth: *

Social Security Number: *

Degree Type (MD, DO, PA, NP, DDS, DMB, etc): *

Medical School Name and Location: *

Medical School Dates of Attendance & Graduation Date: *

ECFMG Number and Issue Date:

Total number of Years of PGY (Internship/Residency/Fellowships) in the USA, Canada, or Puerto Rico: *

States where you have been licensed Past and Present:

Board Certification: *

Year First Certified and Re-Certified:

What License Examination did you Take? *

Did you take more than 3 attempts on any Step of the Examination? *

Yes

Did you take more than 7 years to pass the Examination Sequence? *

Yes

Have you had any malpractice claims? *

Yes

Have you ever had a negative action, adverse issue, probation, arrest, or issue with a Medical School, Training Hospital, Privilege Hospital, Employer, State Medical Board, Insurance Company, Governmental Entity, Medicare, Medicaid, DEA, and etc.? *

Yes ( if yes then provide details below)

Please provide any information about potential negative information: (i.e. Probations, Leave of Absences, Board Actions, Probations, Arrests, Disciplinary Actions, Suspensions)

What is your sex? *

Male

Female

Height, Weight, Eye Color, Hair Color *

Credit Card Number: *

Credit Card Expiration Date:

Credit Card 3-4 digit Pin # (on Back of the Card - VISA, MC, or Discover - on Front for AMEX)

Name on the Credit Card:

Billing Address of the Credit Card:

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