Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs (Rev 12/19)
Medical Board of California
Explanation for Application Question
This form may be used to provide a detailed written explanation
for a
“yes” response to a question on the Board’s application.
A separate form is required for each question.
Licensing Program
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815-
Phone: (916) 263-
Fax: (916) 263-
PERSONAL INFORMATION
Legal Name
Date of Birth U.S. SSN or ITIN Medical School of Graduation
DETAILED WRITTEN EXPLANATION
Application Question Number:
(List corresponding question number from Application)
I hereby declare un
der penalty of perjury under the laws of the State of California that all information contained
on this form is true and correct. Any omission, falsification, or misrepresentation on this attachment
sufficient basis for denying a license.
SIGN LEGAL NAME:
DATE:
Applicant’s signature and date are required
