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Instructions

Application for Certificate of Qualification Under the Retired Senior Volunteer Physician Program (RSVP)

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

Before you begin this application, review the list below and ensure you have each of the required documents. Once you begin the application process, you will not have the opportunity to save and complete the application at a later time. Please ensure you have what is required before beginning the application.

The following items will need to be uploaded during the application process:

Completed and signed Declaration of Citizenship form

Proof of citizenship from List A or List B

Current photograph taken within 60 days prior to the date of this application

Please review the Board’s rules for obtaining a Certificate and Limited License under Retired Senior Volunteer Program at Administrative Rule 540-X-3-.24

There is no fee associated with this application.

Please have your clinic visit our website at https://www.albme.org/Documents/Forms/RSVPcert.pdf to print and complete the Certification of Free Medical Clinic form. Once the form is complete the clinic will need to return it via mail or email.

To the Alabama Board of Medical Examiners:

I hereby make application for a limited certificate of qualification to practice medicine in the state of Alabama under the RSVP, and submit the following statement concerning my age, moral character, preliminary and medical education and practice:

Demographics

First Name

Middle Name

Last Name

Alternate Name(s)

MD or DO

SSN

Suffix

*(Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete and no license will be issued.)

Place of Birth

Country of Birth

State/Providence of Birth

City of Birth

Date of Birth

Gender

Contact Information

The address and contact methods provided should be how the Board or Commission can contact the license applicant directly. Please DO NOT provide contact information for office managers, assistants, or license credentialing agencies.

Address

Country

Street

Apt/Suite

City

State

Zip

County

Contact Methods

Email Address

Home Telephone Number

Work Telephone Number

Upload a color photograph taken within 60 days prior to the date of this application

Education Information

When entering dates attended in the education sections if you don't know the exact date use the first date of the month. (Example: you attended from August 1990 - July 1994, enter 08/01/1990 - 07/01/1994)

Pre-Medical Education

Medical Education

Post-Graduate Medical Education Training

Certification

I hereby certify that I am now or was licensed to practice medicine in the states of

, that my license to practice medicine in each of the states indicated is now or was on the date of expiration unrestricted and in good standing and that there are no currently pending disciplinary actions or investigations concerning my license in any of the states listed above. I further certify that my license to practice medicine in the states listed above has never been revoked, suspended, placed on probation, or otherwise subject to disciplinary action and that I have not had my hospital medical staff privileges revoked, suspended, curtailed, limited, or surrendered while under investigation.

I certify that I am fully retired from the active practice of medicine; however, I wish to volunteer my services as a physician in a free medical clinic located in

Alabama, and it is my expectation that I will provide not less than 100 hours of voluntary services for the calendar year.

I understand and acknowledge that issuance of a certificate of qualification and license to practice medicine under the Retired Senior Volunteer Physician Program requires that I comply with the continuing medical education requirement for physicians as specified in Chapter 14 of the rules of the Alabama Board of Medical Examiners.

Declaration of Citizenship

DECLARATION OF CITIZENSHIP AND LAWFUL PRESENCE OF AN ALIEN FOR PUBLIC BENEFITS AND LICENSING/PERMITTING PROGRAMS

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt “qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive covered state or local public benefits.

With certain exceptions, Ala. Code § 31-13-1, et. seq. prohibits aliens unlawfully present in the U.S. from receiving state or local benefits. Every U.S. Citizen applying for a state or local public benefit must sign a Declaration of Citizenship, and the lawful presence of an alien in the U.S. must be verified by the Federal Government.

Ala. Code § 31-13-1, et. seq. also requires every individual applying for a permit or license to demonstrate his/her U.S. citizenship or if the applicant is an alien, he/she must demonstrate his/her lawful presence in the United States.

Upload Declaration of Citizenship (completed form and supporting documentation)

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.

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.

Date

Applicant’s typed name

Review Page – If everything is correct, press “Next”

Submit

E-Signature :

Date

List all schools attended, undergraduate work other than medical school, dates attended, and degree conferred.

N/A

School Name

Start Date

End Date

Degree Received

List all medical schools attended, dates, and complete addresses of institutions. Do Not list post-graduate medical education training.

Medical School Name

Start Date

End Date

Street Address

Apt/Suite

City

State

Zip Code

Country

List all post-graduate medical education training since graduation from medical school, dates, and complete addresses of institutions. DO NOT list practice experience.

Facility Name

Start Date

End Date

Street Address

Suite

City

State

Zip Code

Country

Alabama	Alaska	Alberta	American Samoa	Arizona
Arkansas	Armed Forces Americas	Armed Forces Canada	Armed Forces Europe (FPO)	Armed Forces Pacific (APO)
British Columbia	California	Canada	Colorado	Connecticut
Delaware	District of Columbia	Fed St Micronesia	Florida	Georgia
Guam	Hawaii	Idaho	Illinois	Indiana
Iowa	Kansas	Kentucky	Louisiana	Maine
Manitoba	Marshall Islands	Maryland	Massachusetts	Michigan
Minnesota	Mississippi	Missouri	Montana	Nebraska
Nevada	New Brunswick	New Hampshire	New Jersey	New Mexico
New York	Newfoundland	North Carolina	North Dakota	Northern Mariana Island
Northwest Territories	Not Known	Nova Scotia	Nunavut	Ohio
Oklahoma	Ontario	Oregon	Other Country	Palau
Pennsylvania	Prince Edward Island	Puerto Rico	Quebec	Rhode Island
Saskatchewan	South Carolina	South Dakota	Tennessee	Texas
Unknown	Utah	Vermont	Virgin Islands	Virginia
Washington	West Virginia	Wisconsin	Wyoming	Yukon

RETIRED SENIOR VOLUNTEER