MDDO Application

Demographics

Board Name

License Type

First Name

Middle Name

Last Name

Suffix

SSN

Date of Birth

Gender

Birth City

Birth State

Birth Country

Address For Public

Address Type

Address1

Apt/Suite

City

State

Zip

Country

Phone

Address For Board

Address Type

Address1

Apt/Suite

City

State

Zip

Country

Phone

Other State Licenses

Education

Medical Education Training

Post Graduation Training

Exam

Chronology of Activities

Malpractice Liability

Pre-Medical Education

From Date

To Date

School

Degree

Intended Residence

Please provide a brief description and the location of your intended medical practice in the State of Alabama:

Hospital Privileges

N/A

Hospital Privileges

Specialty(s)

Specialty (Type of Practice) :

Specialty Board Certification

Are you CURRENTLY certified by one of the specialty boards approved by the American Board of Medical Specialties or the American Osteopathic Association? If yes, have your specialty board send verification to the Board.

Yes

Have you been certified or re-certified within the past ten years by one of the specialty boards approved by the American Board of Medical Specialties or the American Osteopathic Association?

Yes

SPEX

Have you successfully completed a written licensing examination within the last ten years?

Yes

List A

DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP

(1) The applicant's driver's license or nondriver's identification card issued by the division of motor vehicles or the equivalent governmental agency of another state within the United States if the agency indicates on the applicant's driver's license or nondriver's identification card that the person has provided satisfactory proof of United States citizenship.

(2) The applicant's birth certificate that satisfactorily verifies United States citizenship.

(3) Pertinent pages of the applicant's United States valid or expired passport identifying the applicant and the applicant's passport number.

(4) The applicant's United States naturalization documents or the number of the certificate of naturalization

(5) Other documents or methods or proof of United States citizenship issued by the federal government pursuant to the Immigration and Nationality Act of 1952, and amendments thereto.

(6) The applicant’s Bureau of Indian Affairs card number, tribal treaty card number, or tribal enrollment number.

(7) The applicant’s consular report of birth abroad of a citizen of the United States of America.

(8) The applicant’s certificate of citizenship issued by the United States Citizenship and Immigration Services.

(9) The applicant’s certification of report of birth issued by the United States Department of State.

(10) The applicant’s American Indian card, with KIC classification, issued by the United States Department of Homeland Security.

(11) The applicant’s final adoption decree showing the applicant’s name and United States birthplace.

(12) The applicant's official United States military record of service showing the applicant's place of birth in the United States.

(13) An extract from a United States hospital record of birth created at the time of the applicant's birth indicating the applicant's place of birth in the United States.

List B

DOCUMENTS INDICATING STATUS OF QUALIFIED ALIENS, NONIMMIGRANTS, AND ALIENS PAROLED INTO U.S. FOR LESS THAN ONE YEAR

The documents listed below that are registration documents are indicated with an asterisk (“*”).

a. “Qualified Aliens” Evidence of “Qualified Alien” status includes the following:
Alien Lawfully Admitted for Permanent Residence
  • Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
  • Unexpired Temporary I-551 stamp in foreign passport or on * I Form-94.
Asylee
  • * Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
  • * Form I-688B (Employment Authorization Card) annotated “274.a12(a)(50”;
  • * Form I-766 (Employment Authorization Document) annotated “A5”;
  • Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or
  • Order of an immigration judge granting asylum.
Refugee
  • * Form I-94 annotated with stamp showing admission under § 207 of the INA;
  • * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or
  • * Form I-766 (Employment Authorization Document) annotated “A3”
Alien Paroled Into the U.S. for at Least One Year
  • * Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one year requirement.)
Alien Whose Deportation or Removal Was Withheld
  • * Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10);
  • * Form I-766 (Employment Authorization Document) annotated “A10”; or
  • Order from an immigration judge showing deportation withheld under §243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under § 241(b)(3) of the INA.
Alien Granted Conditional Entry
  • * Form I-94 with stamp showing admission under §203(a)(7) of the INA;
  • * Form I-688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or
  • * Form I-766 (Employment Authorization Document) annotated “A3.”
Cuban / Haitian Entrant
  • * Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6;
  • Unexpired temporary I-551 stamp in foreign passport or on * Form I-94 with the code CU6 or CU7; or
  • Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA.
Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty
  • U.S. Citizenship and Immigration Service petition and supporting documentation

Citizenship-U.S. Citizenship or National Status

Are you a citizen or national of the United States?

Yes

Citizenship-Declaration

I understand and agree that by typing my name, I am providing an electronic signature that has the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing information has been provided by me and is true and correct to the best of my knowledge, information and belief.

I declare under penalty of perjury under the laws of the State of Alabama that the answers and evidence I provided are true and correct to the best of my knowledge.

Applicant's Signature

Date

Click Here to request fingerprint cards from the Board. Please note: Fingerprint cards must be mailed to you. Please be sure to include your mailing address with your request to the Board.

Release

certify that all of the information supplied in the foregoing application is true and correct to the best of my knowledge, that the photograph submitted is a true likeness of myself and was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue statement or representation made in this application may result in the revocation of my license to practice medicine and criminal prosecution to the fullest extent of the law.

I further consent to and authorize the release of this application and any information submitted with it or information collected by the Alabama Board of Medical Examiners in connection with this application, including derogatory information, to any person or organization having a legitimate need for the information, and I release the Alabama Board of Medical Examiners from all liability for the release of this information. I further consent to and authorize the release of information, including derogatory information, which may be in the possession of other individuals or organizations to the Alabama Board of Medical Examiners, and I release this individual or organization from any liability for the release of information.

Under Alabama law, this document is a public record and will be provided upon request.

The Alabama Board of Medical Examiners will enforce the Board’s rules and option for the issuance of a Non-Disciplinary Citation and Administrative Charge when an applicant falsifies an application.

Date

Applicant’s typed name

Upload a color photograph taken within sixty days prior to the date of this application.

Review

Payment

Payment Deferral

Date

Total Amount

E-Signature

Payment Type

Person's Name on Card

Card Type

Person's Name on Account

Card Number

Expiration Date (MM/YY)

Security Code

Routing Number

Confirm Routing Number

Account Number

Confirm Account Number

Account Type

Billing Zip

Board of Medical Examiners charge will appear on your statement with a description including IGOVSOL*

Specialty

Please Select your Specialty Board Certification(s):

Primary Specialization

Secondary Specialization

List all hospitals where you have held staff privileges of any type, providing dates, hospital names and complete addresses.

Hospital Name

Start Date

End Date

Street Address

Suite

City

State

Zip Code

Country

ExamType

ExamDate

Number of Attempts

Pass Fail

School Name

Code

City

State

Country

Start Date

End Date

Graduation Date

AccreditationType

Code

Hospital Name

Affiliated Institution

City

State

Country

Specialty

Program Type

Training Status

Begin Date

End Date

LicType

State

License Number

IssueDate

Expiration date

State

Patient Name

Court Name

Role

Claim Status

Insurance Name

Explanation

Event Date

Case Number

Lawsuit Date

Judgement Amount

Behalf Amount

Type

Description

InProgress

Begin Date

End Date

Address

City

State

Zip

Position

Department

Was Employed

Had Staff Privileges

Was Affiliated

Percentage Clinical

Percentage Administrative

Application-MDDO