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MedLicense.com
Professional Medical Licensure in all 50 States
770.456.5932 info@medlicense.com
States where you want to obtain a Medical License:
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Do you wish for MedLicense.com to utilize the ILMC Compact if you qualify?
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Yes - use the ILMC Compact IF I qualify
No - don't use the ILMC Compact
Are you currently Active Military?
NO - Not Active Military
YES - Active Military
Are you CURRENTLY completing an Internship, Residency, or Fellowship?
No
Yes
Full Legal Name (on Identity Documents and Medical School Diploma):
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Mailing Address: ( include Street, City,State, Zip)
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Phone Number:
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Email:
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Date of Birth:
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Place of Birth:
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Social Security Number:
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Degree Type (MD, DO, PA, NP, DDS, DMB, etc):
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Medical School Name and Location:
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Medical School Dates of Attendance & Graduation Date:
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ECFMG Number and Issue Date:
Total number of Years of PGY (Internship/Residency/Fellowships) in the USA, Canada, or Puerto Rico:
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States where you have been licensed Past and Present:
ABMS OR AOA Board Certification:
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Year First Certified and Re-Certified:
What License Examination did you Take?
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Did you take more than 3 attempts on any Step of the Examination?
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Yes
No
Did you take more than 7 years to pass the Examination Sequence?
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Yes
No
Have you had any malpractice claims?
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Yes
No
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.?
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Yes ( if yes then provide details below)
No
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?
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Male
Female
Height, Weight, Eye Color, Hair Color
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Credit Card Number:
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Credit Card Expiration Date:
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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:
I understand and affirm that MedLicense.com does not guarantee that a medical license will be issued. I also understand and affirm that MedLicense.com does not guarantee or warranty the time it will take for my application(s) to be brought to completion or the time it will take for the Medical Board to issue the medical license.
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I Agree
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