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Personal Information:
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First Name Middle Last Name M.D or D.O? Suffix Social Security #
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Home address City State Zip Home Tele# Cell Phone #
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Work address City State Zip Work Tele #
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Preferred mailing address:
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Home
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Work
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Email address:
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Marital Maiden or Previous Name/s Dates for previous name Birth Date
Status
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Birth Place US Citizen? Languages Spoken/Read
(city/state/country)
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U.S. Military Experience:
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Branch Dates of Service Rank Discharge Status Discharge Date
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Physical Characteristics:
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Height Weight Gender Eye Color Hair Color Race
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Physical Marks Location
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Education: List all undergraduate, graduate and medical education beginning with high school.
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Institution City/State Program of Study Dates: From / To Degree Awarded
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Exact medical school graduation date:
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Month/Day/Year
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Foreign Medical Graduates:
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Did you attend a fifth pathway program?
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Yes
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No
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ECFMG Certificate #
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Issue Date
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Did you complete clinical clerkships in a country
other than where your medical school is located?
If you answer "Yes" please provide us with a
copy of the clerkships performed in the U.S.
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Yes
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No
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Medical Exam History: List all licensing exams you have ever taken including FLEX, USMLE,
SPEX, NBME, NBOME, LMCC or SBME.
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Exam Part/Step Date Taken State # of Attempts
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If applicable: Number of Years to complete all 3 Steps of USMLE:
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Post Graduate Training : List all U.S. internships, residencies and fellowships in date order
whether completed or not.
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PGY 1 Facility Name Address, City, State Program Director's Name
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*Program Type/Department Dates: From /To Certificate Earned?
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PGY 2 Facility Name Address, City, State Program Director's Name
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*Program Type/Department Dates: From /To Certificate Earned?
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PGY 3 Facility Name Address, City, State Program Director's Name
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*Program Type/Department Dates: From /To Certificate Earned?
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PGY 4 Facility Name Address, City, State Program Director's Name
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*Program Type/Department Dates: From /To Certificate Earned?
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*All above programs were ACGME approved.
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Yes
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No
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Any comments... additional information or training... unusual circumstances?
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DEA #
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Date Issued:
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Date Expires:
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Do you have a Federation Credential Verification Service (FCVS) Profile established or in process?
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Yes
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No
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If Yes - FCVS Profile #
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Medical Licenses: List all ever held regardless of current status.
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Status
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State
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Type
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Number
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Issue Date
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Exp. Date
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Original state of licensure:
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Date you legally first began to practice medicine:
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(mm/dd/yy)
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Practice / Employment / Hospital Affiliation History: Medical license applications require all time
be accounted for since graduation from medical school. Please list all activities (except PGT)
including employment, hospital affiliations (note type of privilege), locum tenens assignments,
unemployment and vacation since graduation from medical school. You may substitute your CV
if there are no gaps. Be sure to include month and year.
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Practice/employment/hospital Address Dates: From / To Type
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Certification:
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Are you Board Certified?
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Yes
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No
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Specialty?
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Subspecialty?
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Specialty Board Name Date Certified Date Recertified Intending to Sit for Boards?
Specify Date
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Peer References: List four (4) MD’s who can attest to your current clinical abilities, ethical
character and ability to work cooperatively with others. These should be individuals who will
provide written comments on these matters upon request.
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1. Name Telephone # 2. Name Telephone #
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3. Name Telephone # 4. Name Telephone #
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Professional Memberships: List professional memberships and societies, past and present.
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Name of Society / Association Address Dates Affiliated
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Have you been named in a malpractice claim?
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Yes
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No
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If yes, how many?
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Can you provide copies of initial complaint(s) and/or
the Settlement of Dismissal Page for each case?
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Yes
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No
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Please list: any adverse actions taken by a medical school, hospital, licensing board, etc.; if you’ve ever been charged
with, or found guilty of a violation of any federal, state, or local statute; any unusual circumstances:
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Thank you for completing our service application. We look forward to working with you.
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I wish to obtain the services of Medical License Direct, LLC (MLD)
for the following state/s (please list priority order):
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Method of payment:
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The fee for this service is:
• $525 per state ($450 per state for residents)
• $500 per state for three or more states at one time
• $475 per state for five or more states at one time
• $450 per state for ten or more states at one time
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Visa
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Check
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MasterCard
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Money Order
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Discover
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Cardholder Name:
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Mail check to:
Medical License Direct, LLC
11242 South Lakeview Drive
Milton, FL 32583
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Account Number:
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Expiration Date:
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Billing Address
Zip Code:
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Amount to Charge:
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How did you find us?
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By clicking on the "Submit" button you agree to the terms herein.
We’ll be in touch soon to confirm receipt of your application and payment.
Thank you again!
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