Fillable Service Application - Service Application 2009

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Service Application - Service Application 2009

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Medical License Direct, LLC PHONE: 850-471-8648 ~ fax 904-339-9671
4020 Collingswood Rd. www.medicallicensedirect.com
Pensacola, FL 32514 admin@medicallicensedirect.com
Service
Packet
Please type responses directly on form, print to sign service agreement and release, and email, fax or mail
to us. You may substitute a current CV for portions of form. Thank you for your business.
First Name Middle Last Name Suffix MD or DO? Social Security #
Home address City
State Zip
Home Telephone # Cell Phone #
Work address City State Zip Work Telephone #
Preferred mailing address: Home Work Email address:
Marital Status Maiden or Previous Name/s Dates when previous name was used Birth Date
Birth Place US Citizen? or Citizenship Status? Languages spoken/read other than English?
(city/state/country)
U.S. Military Experience:
Physical Characteristics:
Branch Dates of Service Rank Discharge Status Discharge Date
Height: Weight: Gender: Eye Color: Hair Color:
Race: Physical Marks: Location:
Education - List all undergraduate, graduate and medical education beginning with high school:
Institution Name and Complete Address
Program of Study
Dates: From / To
Months and Years
Degree
Awarded
Exact medical school graduation date:
(mm/dd/yy)
Foreign Medical Graduates:
ECFMG Certificate: Number: Issue Date:_
Did you attend a fifth pathway program? Yes No
Did you complete clinical clerkships in a country other than where your medical school is located? Yes No
www.medicallicensedirect.com Service Packet page 2
Medical Exam History – List all licensing exams you have ever taken including FLEX, USMLE, SPEX, NBME, NBOME, LMCC or
State Board Medical Exam.
Exam Part/Step Date Taken State # of Attempts
Post Graduate Training – List all U.S. internships, residencies and fellowships in date order whether completed
or not:
Institution Name and Complete Address
* Program Type/Department
Dates: From / To
Months and Years
Certificate
Earned?
*All above programs were ACGME approved. Yes No
Federal DEA #
Date Issued: Date Expires: State Issued:
Do you have a Federation Credential Verification Service (FCVS) Profile established or in process? Yes No
If yes, Profile #
Medical Licenses - List all ever held regardless of current status:
State
Type (MD, DO, PA, RN, etc.)
License number
Issue Date
Exp. Date
Status
Service Packet page 3
List ALL Practice, Employment, Group and Hospital Affiliation History: Please list all activities (except
training) including employment, hospital affiliations, groups, locum tenens assignments, unemployment and
leaves of absences since graduation from medical school. You may substitute your CV if it’s current, has start
and end months and years for all activities since graduation from medical school and there are no gaps in
time.
Practice or Employment or Hospital Name and Complete Address:
Type of position
or affiliation:
Dates: From / To
Months and Years
Certification:
Are you Board Certified? Yes No If not, are you intending to sit for boards? Specify date/s:
Specialty Board Name
Date Certified
Date/s Recertified
Certificate #
Peer References: List four (4) MD’s who will attest in writing to your current clinical abilities, ethical character
and ability to work cooperatively with others.
Name
Telephone #
Email Address
1. Have you ever been named in a malpractice claim? Yes No If yes, how many?
2. Can you provide copies of initial complaint(s) and/or the settlement/dismissal for each case? Yes No
3. Please list: any adverse actions or any unusual circumstances with a medical school, hospital, licensing board, etc. or if
you’ve ever been charged with, or found guilty of a violation of any federal, state, or local statute:
www.medicallicensedirect.com
Medical License Direct, LLC phone 850-471-8648 ~ fax 904-339-9671
4020 Collingswood Rd. www.medicallicensedirect.com
Pensacola, FL 32514 admin@medicallicensedirect.com
Service
Agreement
Service includes Medical License Direct, LLC (MLD) administrating and preparing my medical license
application/s and related documents. It does not include the fees charged by the state medical board/s for
application and licensure, various other agencies that charge for third party verification, or shipping and
handling fees. MLD will provide an itemized invoice showing third party verification fees along with my
completed medical license application for review and signature. MLD will begin processing application/s
upon receipt of this signed agreement and payment. I understand this application does not entitle me to a
state medical license and that MLD does not issue medical licenses nor provide legal advice concerning the
medical licensure process. Also, medical licensing boards issue medical licenses; therefore MLD cannot
guarantee time estimates. I agree that MLD and its representatives who provide this information to the state
medical board/s in good faith shall not be liable for any act or omission on my part related to the evaluation
or verification of the information contained in my application. I also understand that incomplete or
inaccurate
information, additional research or time needed beyond usual and customary time needed to process my
application due to issues in my background or delays on my part may cause processing
delays
and
additional fees. I agree to not hold MLD liable for these delays. Files placed on hold, after a period of
inactivity of at least 45 days on my part, may later be billed at the current hourly rate to reactivate file or redo
any stale documents. Files may be closed after a period of 90 days of inactivity on my part, and I understand that
another service fee will be required if I decide to start over. By signing this agreement I acknowledge I have
read and agree with these statements and policies listed on www.medicallicensedirect.com/policies
The fee for this service is:
•
$545 per state for MDs and DOs or $525 per state if paid by check
•
$490 per state for MDs and DOs for ten (10) or more states at one time or $475 per state for ten (10) or
more states at one time if paid by check
I wish to obtain the administrative licensing services of Medical License Direct, LLC (MLD) for the following
state/s:
.
Client Signature:
Date:
Print Name:
Please select a method
of payment:
$ Check or money
order enclosed.
Cardholder Name:
(Please print name as it appears on the card)
Account Number:
OR
$ Amt. to charge
Please check one:
VISA®
MasterCard®
Discover®
Card Expiration Date:__________ CVV/Security Code # on back of card: ________
Billing address:
Billing City, ST, Zip:
Cardholder Signature Current Date
How did you find us? Referred by: ________________________ Search engine used: ________________
Search term used: _________________________________________________________________________
Thank you.
RELEASE AND AUTHORIZATION
I, , hereby make this release and waiver of rights for the purpose
of allowing Medical License Direct LLC and its agents to carry out its duties pursuant to my request
for a license to practice medicine/osteopathy in mutually agreed upon states.
I authorize the following to release information about me in their possession to the medical licensing
board and/or Medical License Direct LLC or their agents: all hospitals, medical institutions or
organizations, personal references, employers, business and professional associates, specialty
boards, medical licensure boards, university transcript offices, medical schools, malpractice insurance
companies, attorneys who have participated in civil or criminal actions in which I was named party
that pertain to or directly affect my ability to obtain or retain a state medical license and/or practice
medicine to release to the state medical licensing board and/or Medical License Direct LLC or their
agents any information, files or records required by that particular state medical licensing board for its
evaluation of my professional, ethical and physical qualifications for medical licensure.
I hereby release the above-named individuals and entities from all liability for the release of
information to the state medical licensing board or its agents.
A photocopy of this Release and Authorization shall be as effective as the original.
Applicant’s Signature: Date:
Print Name:
SS#: Date of Birth:
Medical License Direct, LLC
phone 850-471-8648 ~ fax 904-339-9671
www.medicallicensedirect.com
admin@medicallicensedirect.com
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Service Application - Service Application 2009

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Completed 24 July 2020

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