Wisconsin Department of Safety and Professional Services · WI Department of Safety and Professional Services, Medical Examining Board Uniform Application Instructions December 2018

WI Department of Safety and Professional Services, Medical Examining Board Uniform Application Instructions

December 2018 Page 1 of 6

Wisconsin Department of Safety and Professional Services

Mail To: P.O. Box 8935 1400 E. Washington Avenue

Madison, WI 53708-8935 Madison, WI 53703

FAX #: (608) 261-7083 E-Mail: [email protected]

Phone #: (608) 266-2112 Website: http://dsps.wi.gov

MEDICAL EXAMINING BOARD

INFORMATION FOR COMPLETING THE UNIFORM APPLICATION

The Uniform Application for Physician State Licensure (UA) is a licensure application shared by many state

boards. After completing the UA, your application is securely stored and can be sent to additional boards accepting

or requiring the UA without reentering the same information. You would only make updates as needed and

complete the state specific requirements for each board. The UA can only be submitted via the Online License

Application System (OLAS).

The Federation Credentials Verification Service (FCVS) can be used in conjunction with the UA but it is not

required. FCVS is used for credential verification only and is not a licensure application. Applicants not using

FCVS must provide credentials to the board for verification. Applicants using FCVS will need to complete an

initial (first time) or subsequent (update) FCVS application before working on the UA. More information is

available at https://www.fsmb.org/fcvs/.

To work on your UA, select “Uniform Application (UA)” from the Sign In menu in the upper right corner of

https://www.fsmb.org/uniform-application/, then sign in and continue as directed.

Completing the Uniform Application

Please read the following information carefully. You will be asked to provide your licensure and employment

history, account for all time since medical school graduation, and provide information on medical malpractice

claims. We recommend having this information on hand before you begin. Failure to submit all required

information and documentation will result in processing delays.

Complete the UA as instructed online. Make special note of the information given below.

• If you indicate on the UA that you have ever used an alternate name or your name is not the same on all

of your submitted documents, you must submit a certified copy of your marriage certificate, divorce

decree, court order, or other document that indicates your legal name change. If you are using FCVS for

credential verification, FCVS will verify your alternate name and send documentation to the Board on

your behalf.

• All nine digits of your social security number must be submitted. If you are using FCVS, manually enter

the missing numbers as FCVS only transfer the last four digits into the UA.

If you do not have a social security number, you must submit a statement under oath or affirmation. If

your social security number or a statement is not provided, your application will be denied (Section

440.03, 11m, Wis. Stats.). A form for submitting a statement that you do not have a social security number

is available from the Board.

mailto:[email protected]

http://dsps.wi.gov/

https://www.fsmb.org/fcvs/

https://www.fsmb.org/uniform-application/



The Department may not disclose the social security number collected except to the Department of

Children and Families for purposes of administering the child and spousal support program (Sections

49.22 and 440.13, Wis. Stats.), to the Department of Revenue for the purpose of determining whether you

are liable for delinquent taxes (Section 440.12, Wis. Stats.), and to the federal Healthcare Integrity and

Protection Data Bank for the purpose of reporting adverse actions against health care practitioners per the

Health Insurance Portability and Accountability Act (HIPAA) of 1996.

• If you are not using FCVS, you must contact the appropriate entity to have a certified transcript of your

scores sent directly to the Board. If you have taken any component of the NBME in conjunction with

another exam (USMLE/FLEX), you must request the transcripts from the NBME. If you are using FCVS,

FCVS will provide this information to the Board for you.

o USMLE/FLEX/SPEX: Request your transcripts by going to http://www.fsmb.org/ and clicking

on Transcripts in the Sign In menu. For questions or assistance, call 817/868-4041 or email

[email protected].

o National Board of Medical Examiners (NBME): Request transcripts and other documents to be

sent to this Board at https://apps.nbme.org/ciw2/prod/jsp/login.jsp. For assistance, call 215/590-

9500 or email [email protected].

o National Board of Osteopathic Medical Examiners (NBOME): Request that a certified copy of

your official transcript be sent directly to this Board at http://www.nbome.org/transcript-

request.asp?m-can. For assistance, call 773/714-0622 or email [email protected].

o State Board Examination: (Reciprocity only for exams taken prior to 1982.) Request certified

scores directly from the state board. The state board submitting the information must include all

of the subjects covered in the examination, scores received, general average, date of the

examination, license number, date of issuance, status of licensure, and any information pertaining

to disciplinary action. See https://www.fsmb.org/uniform-application/ for a directory of state

boards.

o Medical Council of Canada (LMCC): (Must be taken after January 1, 1978.) Visit

http://www.mcc.ca/en/mcc docs/index.shtml to request documents to be sent to the Board. For

questions or assistance, call 613/521-6012 or email MCC [email protected].

o Educational Commission for Foreign Medical Graduates (ECFMG): If you graduated from a

medical school outside of the United States or Canada and are not using FCVS, you must provide

a copy of your ECFMG certificate. Request certified National Boards Part I & II subjects and

scores and a historical record at http://www.ecfmg.org. ECFMG should forward this information

directly to the Board. For questions or assistance, call 215/823-2202 or email [email protected].

• List all other professional licenses you have held (nurse, EMT, etc.) in all states, territories, provinces, or

foreign countries. Include temporary, courtesy, and locum tenens licenses, and instructional or training

permits. All licenses must be verified, with verification including your date of birth, license number, date

of issuance, and a statement regarding disciplinary actions.

The licensure verification information resource at https://www.fsmb.org/uniform-application/ lists each

board’s preferred method of verification as well as verification fees. The information is subject to change

at any time so we highly recommend verifying fees and requirements at the links provided. When using

VeriDoc or a board’s electronic method of verification, you do not need to use the Verification of

Licensure form or the UA’s Licensure Verification form.

If you are using FCVS, you will not need to complete the verification forms related to education or

postgraduate training. FCVS will provide this information to the Board for you.

http://www.fsmb.org/


https://apps.nbme.org/ciw2/prod/jsp/login.jsp


http://www.nbome.org/transcript-request.asp?m-can

http://www.nbome.org/transcript-request.asp?m-can



http://www.mcc.ca/en/mcc_docs/index.shtml


http://www.ecfmg.org/





• On the Chronology of Activities page, the Practice/Employment Name field must contain either a business

name or a description of your non-working time (Health Activity, Military Service, PGT/Education,

Seeking Employment, or Vacation). Provide your home or school address for each non-working time. To

avoid delays in processing, review this information thoroughly after importing into OLAS to ensure the

information is accurate and complete.

• Clinical indicates time spent with patients. Administrative indicates time spent on other tasks, such as

paperwork or research.

• On the Malpractice page, include all settlements, judgments, awards, and claims, even if no money was

paid. For each case listed, provide documentation.

• Complete the licensure verifications and the applicable DSPS forms located on the Board’s website at

http://dsps.wi.gov/LicensesPermitsRegistrations/Credentialing-Division-Home-Page/Health-

Professions/Physician/Physician-Application-Forms/. Use the checklist provided at the end of these

instructions to ensure you complete all required forms.

Review & Submit

Please review all of your entries before submitting. We strongly advise that you print or save a copy for your

records. Any errors will be listed in a red-outlined box with a link to the page that needs to be corrected.

To submit your UA, read and accept the Terms and Conditions, then click on “Submit Application” or “Continue”

at the bottom of the screen. First time UA-users will be taken to a payment page for a one-time service fee of $50.

This is a separate fee collected by FSMB, not by state boards, and is separate from FCVS fees. An itemized receipt

will be available in the Navigation Options menu in the upper right corner.

The “Start New/Edit” link is used for both editing an already submitted UA and for sending the UA to a new state

board. After clicking on that link, select/reselect the appropriate board from the map, make changes or updates if

needed, and send your UA to the selected board.

For assistance, see the Uniform Application FAQ at http://www.fsmb.org/uniform-application/ua-faq/. If your

question is not listed, contact UA customer service at 800-793-7939 or email [email protected] with your username,

FCVS ID if applicable, and a detailed description. Provide a screenshot if you receive an error.

OTHER LICENSURE REQUIREMENTS

Requirements for licensure are listed at http://dsps.wi.gov/LicensesPermitsRegistrations/Credentialing-Division-

Home-Page/Health-Professions/Physician/. In addition to the listed requirements for education, examinations, and

postgraduate training, plus DEA number for prescribing controlled substances, please note the following:

The Data Bank (National Practitioner/Healthcare Integrity and Protection) Self Query

All applicants must request the “Practitioner Request for Information Disclosure” (Self Query) from The Data

Bank. Visit http://www.npdb.hrsa.gov/pract/selfQueryBasics.jsp and click on “Start a Self-Query for an

Individual.” Follow the instructions to receive a self-query report. When finished, print a copy of the form for

yourself and mail it directly to The Data Bank. They will send the Self Query report directly to you. Once received,

send a copy to the Department. This report may be emailed to [email protected] or faxed to 608-

261-7083. For questions or assistance, call 800-767-6732 or email [email protected].

Physician Profile Data Report from AMA or AOA

All MDs applying for licensure must request the AMA Physician Profile Data Report from the American Medical

Association at https://profiles.ama-assn.org/amaprofiles. Select the option for “Physicians Only – Requests for

http://dsps.wi.gov/LicensesPermitsRegistrations/Credentialing-Division-Home-Page/Health-Professions/Physician/Physician-Application-Forms/

http://dsps.wi.gov/LicensesPermitsRegistrations/Credentialing-Division-Home-Page/Health-Professions/Physician/Physician-Application-Forms/

http://www.fsmb.org/uniform-application/ua-faq/


http://dsps.wi.gov/LicensesPermitsRegistrations/Credentialing-Division-Home-Page/Health-Professions/Physician/

http://dsps.wi.gov/LicensesPermitsRegistrations/Credentialing-Division-Home-Page/Health-Professions/Physician/

http://www.npdb.hrsa.gov/pract/selfQueryBasics.jsp



https://profiles.ama-assn.org/amaprofiles



Profiles to be sent to Licensing Boards” and follow the steps given on the AMA website. Call 800-621-8335 for

assistance.

All DOs applying for licensure must request the AOA Official Osteopathic Physician Profile Report at

https://www.doprofiles.org. For questions or assistance, email [email protected].

Oral Interviews

The oral interview process in the State of Wisconsin was created under MED 1.06 of the Administrative Code. If

you are selected to appear for an oral interview, you will be scheduled to appear before the review panel at one of

the regularly scheduled Board meetings.

Panel Review: Oral Interviews

a) An applicant may be required to complete an oral interview if the applicant:

1. Has a medical condition, which in any way impairs or limits the applicant’s ability to practice medicine

and surgery with reasonable skill and safety.

2. Uses chemical substances to impair in any way the applicant’s ability to practice medicine and surgery

with reasonable skill and safety.

3. Has been disciplined or had licensure denied by a licensing or regulatory authority in Wisconsin or another

jurisdiction.

4. Has been found to have been negligent in the practice of medicine or has been a party in a lawsuit in

which it was alleged that the applicant had been negligent in the practice of medicine.

5. Has been convicted of a crime the circumstances of which substantially relate to the practice of medicine.

6. Has lost, had reduced or had suspended his or her hospital staff privileges, or has failed to continuously

maintain hospital privileges during the applicant’s period of licensure following post-graduate training.

7. Has been graduated from a medical school not approved by the Board.

8. Has been diagnosed as suffering from pedophilia, exhibitionism or voyeurism.

9. Has within the past 2 years engaged in the illegal use of controlled substances.

10. Has been subject to adverse formal action during the course of medical education, postgraduate training,

hospital practice, or other medical employment.

11. Has not practiced medicine and surgery for a period of 3 years prior to application, unless the applicant

has been graduated from a school of medicine within that period.

b) An application filed under Med 1.02 shall be reviewed by an application review panel of at least two Board

members designated by the Chairperson of the Board. That panel shall determine whether the applicant is eligible

for a regular license without completing an oral interview. An applicant can also be required to take an oral

interview under Med. 1.08 (2), if the applicant has been examined four or more times before achieving a passing

grade.

Foreign Graduates

If you are not using FCVS for credential verification, provide a copy of your ECFMG certificate with “valid

indefinitely” status as described on page 3. If you participated in a Fifth Pathway program, you must also provide

a copy of your Fifth Pathway Certificate.

Checklists

You will have an online checklist provided by the Board to ensure you complete all requirements. The checklist

provided on the following page is given to help you determine which items are needed if you are using FCVS

and/or applying for certain licenses (Visiting Physician, Temporary Camp Physician, Locum Tenens, and

Physicians seeking licensure via Reciprocity of MN State Board License).

https://www.doprofiles.org/


http://www.fsmb.org/uniform-application/



BASIS FOR LICENSURE / APPLICATION FEES

Administrative Physician If you would like to apply for an Administrative Physician license, please check this box along with the appropriate method below.

Endorsement of Steps 1, 2, and 3 of USMLE Reciprocity of State Board Exam taken prior to 1972

$ 75.00 Initial Credential Fee $ 141.00 Reciprocal Credential Fee

Endorsement of National Boards (NBME/NBOME) Reciprocity of MN State Board License $ 75.00 Initial Credential Fee $ 141.00 Reciprocal Initial Credential Fee

Endorsement of FLEX Temporary Camp Physician License $ 75.00 Initial Credential Fee $ 75.00 Initial Credential Fee

Endorsement of LMCC (Taken after 1/1/78) Locum Tenens License $ 75.00 Initial Credential Fee $ 141.00 Initial Credential Fee

Resident Educational License Visiting Physician

$ 10.00 Initial Credential Fee $ 141.00 Initial Credential Fee

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: [email protected] Phone #: (608) 266-2112 Website: http://dsps.wi.gov


AUTHORIZATION AND WAIVER

Applicant: Please complete and forward this form to all sources that verify information directly to the Wisconsin Medical Examining Board (example: verification of hospital privileges). Provide a copy of this completed form when submitting your application materials to DSPS.

Last Name:

First Name:

Middle Initial:

Former/Maiden Name(s):

Date of Birth: / /

City/State/Country of Birth:

Having filed an application for a license to practice medicine and surgery in the State of Wisconsin, I hereby authorize and consent to have an investigation made as to my professional reputation and fitness for the practice of medicine and surgery. I agree to give any further information, which may be required in reference to my past record. I understand that I may inspect and copy any reports received by the Board relating to my professional reputation and fitness for the practice of medicine and surgery, and that I may submit evidence including documents which tend to mitigate or explain any adverse information received from other parties. I also understand that the contents of my report will be privileged as to all other persons unless determined otherwise by court order.

I also authorize and request every person, hospital, clinic, community, governmental agency, court, association, or institution having control of any documents, records, and other information pertaining to me, to furnish to the Wisconsin Medical Examining Board any such information, including documents, records regarding charges or complaints filed against me, formal or informal, pending or closed, or any of its pertinent data and to permit the Wisconsin Medical Examining Board or any of its agents or representatives to inspect and make copies of such documents, records, and other information.

I hereby release, discharge, and exonerate the Wisconsin Medical Examining Board, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records and other information, or the investigation made by the Wisconsin Medical Examining Board.

Applicant Signature _________________________________________________ Date / /

#571 (Rev. 3/15) Ch. 448, Stats.

Committed to Equal Opportunity in Employment and Licensing

#2164 (Rev. 4/15) Ch. 448, Stats.




MEDICAL EDUCATION VERIFICATION FORM

(Not necessary if utilizing FCVS)

APPLICANT: Please forward this form to your medical school.

MEDICAL SCHOOL: The Medical Examining Board requests that you complete this form concerning the following individual:

Applicant's Name:

Social Security #: (for school use to locate your records) - -

Medical School:

Medical School Address:

YES NO

1. Did this Physician attend the medical school noted above?

2. What were the applicant's dates of enrollment in this medical school?

Start Date: / / End Date: / /

3. Did this Physician graduate from this medical school? If no, please attach explanation on a separate sheet.

Degree Granted: Date Degree Granted: / /

4. Did this Physician take a leave of absence during his/her attendance at this medical school? If yes, please attach explanation on a separate sheet.

5. Did this Physician have a record of unexcused absences during his/her attendance at this medical school? If yes, please attach explanation on a separate sheet.

6. Was this Physician ever disciplined or under investigation during his/her attendance at this medical school? If yes, please attach explanation on a separate sheet.

7. Were any special requirements imposed on this in Physician that were not required of all other students at his/her level of education? If yes, please attach explanation on a separate sheet.

8. Was this Physician recommended for post-graduate training?

Printed Name of Dean:

Signature: ____________________________________________________ Date / /

Medical School, please return directly to:

DSPS Attn: Medical Examining Board P.O. Box 8935 Madison, WI 53708-8935

Or you may fax/email with facility cover sheet/letter to: (608) 261-7083 or [email protected].

#2165 (Rev. 04/15) Page 1 of 2 Ch.448, Stats.




CERTIFICATE OF POSTGRADUATE TRAINING

(Not necessary if utilizing FCVS)

APPLICANT: Please forward this form to your postgraduate training program(s) for completion.

TRAINING PROGRAM: The Medical Examining Board requests that you complete this form concerning the following individual:

Applicant/Physician's Name:

Hospital/Program Name:

Hospital/Program Address:

Hospital/Program’s Daytime Phone: - -

1. In what type and level(s) of training did this Physician participate at your facility? Indicate below each level of training that the above named Physician participated in your program. Provide start/end dates, type of training, and whether credit was given for the training.

DATES OF TRAINING (month/day/year)

TYPE OF SPECIALTY TRAINING

FULL CREDIT

PARTIAL CREDIT

PGY 1:

/ / to / /

Yes

No

Yes

No

PGY 2:

/ / to / /

Yes

No

Yes

No

PGY 3:

/ / to / /

Yes

No

Yes

No

PGY 4:

/ / to / /

Yes

No

Yes

No

Fellowship:

/ / to / /

Yes

No

Yes

No

Other:

/ / to / /

Yes

No

Yes

No

YES NO

2. Was the internship/residency/fellowship in the United States or Canada accredited by the Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA), the Royal College of Physicians & Surgeons of Canada (RCPSC), or the College of Family Physicians of Canada (CFPC)?

#2165 (Rev. 04/15) Page 2 of 2 Ch.448, Stats.



YES NO

3. Did the Physician either complete the training at your facility in good standing, or is the Physician currently in the training program and in good standing? If no, please attach explanation on a separate sheet.

4. Was this Physician recommended for the Board Certification Examination in this specialty?

If you answer Yes to questions 5-14, attach an explanation on a separate sheet.

5. Was the Physician asked, or required, to repeat any portion of the training at your facility?

6. Was the Physician placed on probation, suspended, or in any way sanctioned or disciplined while at your facility?

7. Was this Physician granted a leave of absence while training at your facility?

8. Did this individual have a record of unexcused absences during his/her attendance at this training program?

9. Were any restrictions and/or special requirements placed on this Physician's activities that were not placed on all other residents/fellows at his/her level of training?

10. Were any formal patient or staff complaints filed against this Physician?

11. Were any incident reports filed involving the professional behavior or conduct of this Physician?

12. Was this Physician ever subject to non-routine monitoring while at your facility?

13. Were any malpractice actions filed naming this Physician as a defendant that involved his/her period of training at your facility?

14. Is there any additional information in this Physician's file that would assist the Board in determining this applicant's eligibility for licensure?

FOR PHYSICIANS CURRENTLY COMPLETING SECOND YEAR OF TRAINING AT THIS FACILITY:

15. Has the Physician completed and received credit for 12 consecutive months of training in this program and is expected to continue in the program and complete at least 24 months of post-graduate training?

If yes, please indicate the expected completion date of the 24 months of training: / /

Printed Name of Program Director:

Signature of Program Director: ____________________________________________Date / /

Postgraduate Training Program, please return directly to:

DSPS Attn: Medical Examining Board P.O. Box 8935 Madison, WI 53708-8935

Or you may fax/email with facility cover sheet/letter to: (608) 261-7083 or [email protected].



HOSPITAL, FACILITY, AND EMPLOYER VERIFICATION

APPLICANT: Please forward this form to all hospitals, facilities, and employers where you have had staff privileges, employment, or appointment during the last five (5) years.

Hospital/Facility/Employer: The Medical Examining Board requests that you complete this form concerning the following individual:

Applicant/Physician's Name:

Name of Hospital/Facility/Employer:

Hospital/Facility/Employer’s Address:

Hospital/Facility/Employer’s Daytime Phone: - -

Hospital/Facility/Employer, you must answer all of the following questions and provide any additional information in order for this form to be considered complete.

1. What position did this Physician hold at your facility or under your employment?

2. What were this Physician's dates of employment or staff privileges at your facility?

/ / to / / NOTE: If Physician is still employed/privileged, end date should indicate “to present” or “to current.”

YES NO3. Did this Physician either leave your employment in good standing, or is currently employed and in good

standing? If no, please attach explanation on a separate sheet.

If you answer Yes to questions 4-9, attach an explanation on a separate sheet.

4. Was the Physician placed on probation, suspended, or in any way sanctioned or disciplined while at your facility or under your employment?

5. Was this Physician granted a leave of absence while employed by you or at your facility?

6. Did this Physician have a record of unexcused absences during his/her attendance at this facility or under your employment

7. Were any restrictions or special requirements placed on this Physician's activities that were not placed on all other employees/staff holding similar positions?

8. Were any restrictions placed on this Physician's privileges?

9. Were any formal patient or staff complaints filed against this Physician?

#2167(Rev. 3/15) Page 1 of 2 Ch. 448, Stats.



If you answer Yes to questions 10-15, attach an explanation on a separate sheet. YES NO

10. Was this Physician denied hospital privileges while employed by you?

11. Were any incident reports filed involving the professional conduct or behavior of this Physician?

12. Was this Physician ever subject to non-routine monitoring while at your facility?

13. Was this Physician involuntarily removed from a call schedule for cause?

14. Was this Physician subject to non-routine quality assessment review?

15. Was this Physician the subject of a negative review by a quality assurance or departmental committee?

Name/title of Individual Supplying Information:

Signature: _________________________________ Date / /

Hospital/Facility/Employer, please return directly to:

DSPS Attn: Medical Examining Board P.O. Box 8935 Madison, WI 53708-8935 Or you may fax/email with facility cover sheet/letter to: (608) 261-7083 or [email protected]. #2167(Rev. 3/15) Page 2 of 2 Ch. 448, Stats.


Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 Ship To: 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: [email protected] Phone #: (608) 266-2112 Website: http://dsps.wi.gov

DIVISION OF PROFESSIONAL CREDENTIALING PROCESSING

INFORMATION FOR COMPLETING CONVICTIONS AND PENDING CHARGES FORM

AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:

Important Notice: Incomplete information will delay the processing time.

If you have been convicted of a crime or have criminal charges pending against you, complete this form and return it with your

application, application fee, and an additional $8.00 conviction review fee. If you obtained fingerprints as a requirement for

your application, you do not need to submit the $8.00 fee. Please consult the “Frequently Asked Questions” on page ii for

more information on completing this form.

List all felonies, misdemeanors, and other violations of federal, state, or local law, including municipal ordinances resulting only in

monetary fines or forfeitures, of which you have ever been convicted, in this state or any other. This includes convictions resulting

from a plea of no contest, a guilty plea, or verdict. For each conviction or violation, list the type of offense, date, and location.

Violations for which you received a ticket and paid a fine must be reported. You do not need to report dismissed charges. If you have

charges pending, see page 3 for a list of required documents.

For each Conviction, it is your responsibility to submit the following documents:

Note: Do not submit CCAP printouts. They do not satisfy documentation requirements and cause delays in processing.

Certified copies of the Police Report or Criminal Complaint:

Contact the Police Station(s) for copies of Police Report(s). Contact the Court(s) for copies of Criminal Complaint(s).

Judgment of Conviction and Sentencing:

Contact the Court(s) for Judgment(s) of Conviction.

Sentencing Verification:

Contact the Court(s) for copies of documentation indicating that you completed the terms of your sentence, including but not

limited to, documents such as a letter from the Department of Corrections stating that you completed probation, jail time, a

receipt from paying a fine, etc.

Chemical Dependency Assessment(s) (Commonly referred to as ‘AODA,’ submit if court-ordered.)

Personal Statement for each conviction:

The statement must include a description of the facts that led to the conviction, including who was involved, where you were,

what happened and why, the penalties imposed, and verification that you completed all sentencing requirements. If you have

alcohol and/or drug related convictions or pending charges, please include a statement describing your current usage of alcohol

and/or drugs.

$8.00 CIB Review Fee (if applicable)

If you discover the required information is not available after contacting the appropriate agency/police department, and/or court,

please indicate this in a personal statement and submit the personal statement to DSPS, along with any documentation that is available.

The Fair Employment Act (Wis. Stat. §§ 111.31-111.395) prohibits employment discrimination on the basis of conviction record or

arrest record unless the circumstances of the conviction or arrest substantially relate to the circumstances of the particular job or

licensed activity. The information requested on this form will be used to determine whether your application should be granted,

approved with limitations, or denied. The information you provide on this form may be verified against criminal information records.

Omission of information on this form will be considered a false statement on an application.

#2252 (Rev. 11/15)

Wis. Stat. § 111 i Committed to Equal Opportunity in Employment and Licensing


http://dsps.wi.gov/


FREQUENTLY ASKED QUESTIONS

1. If I was charged with a crime but not convicted, do I need to report that or submit any documents?

Send in a court document stating either that the charges were dismissed or that you were acquitted. If you entered

into a deferred prosecution agreement, submit a copy of the agreement and verification that you have complied with

all terms and conditions of the agreement.

2. If the conviction was expunged, do I need to report or submit anything?

If a court has expunged your conviction, you must still disclose the conviction and provide all documents required

for Form # 2252. Include a court document stating that the conviction was expunged.

3. What do I do if records are no longer available due to the length of time that has passed since the conviction?

If, after contacting the appropriate records custodian (Court, Police Department, etc.), you find that documents are

not available and the conviction or ordinance violation is more than five years old, indicate that the records are no

longer available for that offense in your personal statement. If the conviction was a misdemeanor or ordinance

violation and within the last five years, you must include a letter from the records custodian confirming the

unavailability of the records. If the conviction was a felony and within the last 10 years, you must include a letter

from the records custodian confirming the unavailability of the records.

4. Do I need to report or submit anything about minor traffic violations, i.e. a speeding ticket?

There is no need to disclose most traffic violations, unless the traffic violation involves alcohol or other drug use

(including Operating While Intoxicated convictions), then they must be disclosed.

5. How can I find out if I am excluded from getting a license due to a conviction?

Whether an applicant will or will not be issued a license based on a conviction record is determined on a case-by-

case basis. Each profession is regulated by its particular statutes and rules. Please refer to the statutes and rules of

the profession for which you are applying in order to determine whether your conviction records are substantially

related to the practice of the profession.

6. How long does it take to review these documents?

The time period for conviction review varies depending on a variety of factors, including whether all required

information and documentation has been submitted, whether the conviction record needs to be reviewed by the board,

etc.

7. What are certified court records and where do I get them?

These are records certified as true and correct by the Office of the Clerk of Courts and may include judgment of

conviction, police report/incident report/criminal complaint, court-ordered assessment report, etc. Records may be

obtained from the Office of the Clerk of Courts in the county in which your case was heard or relevant police

department.

8. If I was underage at the time of the offense, do I need to report or submit anything?

Yes, report the conviction. You must submit all court documents and verification that you have complied with all

sentencing requirements. Any conviction received while underage involving alcohol (including convictions for

Operating While Intoxicated) or other drug use must also be disclosed.

9. What needs to be in the personal statement?

A personal statement should describe the events that led to each offense and conviction listed on Form # 2252, along

with an explanation of the penalties imposed, and verification that you completed all sentencing requirements. The

statement should address the “who,” “what,” “when,” “where,” “how,” and “why” of the circumstances that led to

each conviction. Include any information about changes in your life that you would like to be considered, including

past and current alcohol and/or drug treatment programs, whether you completed those programs, and, if not, why

not.

10. Do I need to hire a lawyer?

It is your decision as to whether you hire an attorney. If you decide you want a legal opinion from an attorney, you

would need to hire a private attorney, as the legal department of DSPS does not provide legal advice to applicants.

#2252 (Rev. 11/15)

Wis. Stat. § 111 ii Committed to Equal Opportunity in Employment and Licensing

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 Ship To: 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: [email protected] Phone #: (608) 266-2112 Website: http://dsps.wi.gov

DIVISION OF PROFESSIONAL CREDENTIALING PROCESSING

CONVICTIONS AND PENDING CHARGES FORM

Under Wisconsin law, the Department must deny your application if you are liable for delinquent State Taxes or Child Support (Wis. Stat. § 440.12).

PLEASE TYPE OR PRINT IN INK Your name and address are available to the public. Check box to withhold street address/PO Box number from lists of 10

or more credential holders (Wis. Stat. § 440 14).

Profession Application/License #

Last Name First Name MI

List All Other Names Used

Date of Birth Social Security # Your Social Security Number or Employer Identification Number must be submitted with

your application on this form. If you do not have

a Social Security Number, you must complete Form #1051. The Department may not disclose

the Social Security Number collected except as

authorized by law.

/ / - -

Email Address

Daytime Telephone Number

- -

APPLICATION FEES: Please check applicable box. Make check payable to

DSPS and attach to this form. For Receipting Use Only

CIB Review Fee

$ 8.00 Total Fee Attached (only required if you were not fingerprinted as a requirement of your application)

#2252 (Rev. 11/15)

Wis. Stat. § 111 Page 1 of 4 Committed to Equal Opportunity in Employment and Licensing


http://dsps.wi.gov/

Wisconsin Department of Safety and Professional Services FORM IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED.

FOR EACH CONVICTION LISTED BELOW, SUBMIT:

Personal Statement

Form #2252 and appropriate fee(s)

Judgment of Conviction and Sentencing

Sentencing Verification

Chemical Dependency Assessment(s)

(if alcohol or drug-related convictions)

Certified copies of the Police Report or

Criminal Complaint

NOTE: Do not submit CCAP printouts. They do not satisfy documentation

requirements and cause delays in processing.

List all felonies, misdemeanors, or other violations of federal, state, or local law or municipal ordinance.

Attach additional sheet(s) if necessary.

CONVICTION DATE OF CONVICTION LOCATION (City/State)

/ /

/ /

/ /

/ /

/ /

/ /

YOU MUST ANSWER THE FOLLOWING QUESTIONS (Attach additional sheet(s) if necessary)

1. Have you ever been sentenced by a court to participate in an alcohol or other drug assessment, treatment or

counseling program?

Yes No

If yes, did you successfully complete the program? If so, attach a certificate of completion/discharge

summary.

If you did not complete the program, attach a personal statement explaining why.

Yes No

2. Have you ever been placed on probation? Yes No

If yes, did you successfully complete the probation?

If you are currently on probation, you must request your probation officer to send a letter describing

your current probation requirements and your compliance with supervision.

Yes No

3. Have you ever been placed on parole? Yes No

If yes, did you successfully complete parole?

If you are currently on parole, you must request your parole officer to send a letter describing your

current parole requirements and your compliance with supervision.

Yes No

4. Have you ever been ordered to pay restitution? Yes No

If yes, did you successfully pay the restitution? Yes No

#2252 (Rev. 11/15)


Wisconsin Department of Safety and Professional Services FORM IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED.

FOR EACH PENDING CHARGE LISTED BELOW, SUBMIT: Personal Statement

Form #2252 and appropriate fee(s)

Certified copies of the Police Report

or Criminal Complaint

NOTE: Do not submit CCAP printouts. They do not satisfy documentation

requirements and cause delays in processing.

List all pending felonies, misdemeanors, or other violations of federal, state, or local law or municipal ordinance.

Attach additional sheet(s) if necessary.

PENDING CHARGE DATE OF ARREST LOCATION (City/State)

/ /

/ /

/ /

/ /

/ /

/ /

PLEASE TAKE NOTICE: IT IS YOUR RESPONSIBILITY TO SUBMIT ALL REQUIRED PAPERWORK FOR

PROCESSING. CCAP PRINTOUTS DO NOT SATISFY DOCUMENTATION REQUIREMENTS AND CAUSE

DELAYS IN PROCESSING.

#2252 (Rev. 11/15)



PERSONAL STATEMENT FOR EACH CONVICTION AND/OR PENDING CHARGE:

(Attach additional sheet(s) if necessary.)

Provide a personal statement for each conviction and/or pending charge. In each personal statement, describe the facts that led to each

offense (i.e. who was involved, where you were, what happened, and why), penalties imposed, and verification that you completed all

sentencing requirements.

Example of an Adequate Personal Statement: “In 2011, I was convicted of an OWI 1st. I was out with friends for a birthday party.

I drank too much at the bar and made the poor decision to drive myself home. On the way home, I was pulled over for speeding. I

failed the field sobriety test and blew a “.10.” I was ticketed, paid a fine, and had my driver 's license was suspended. I was also

sentenced to do an alcohol and drug (AODA) assessment and attend treatment classes. Attached to this statement are copies of the

police report from my arrest, a copy of the judgment of conviction, my AODA assessment, and records showing that I successfully

completed alcohol counseling and treatment courses.” If you have alcohol and/or drug related convictions or pending charges, please

include a statement a describing your current usage of alcohol and/or drugs.

CONVICTION(S):

PENDING CHARGE(S):

CONTINUING DUTY OF DISCLOSURE

I understand that I have a continuing duty of disclosure during the application process. If information I have provided in this

application becomes invalid, incorrect or outdated, I understand that I am obliged to provide any necessary information to ensure the

information on my application remains current, valid, and truthful. I understand that Credentialing authorities may view acts of

omission as dishonesty and that my duty of disclosure during the application process exists until licensure is granted or denied.

AFFIDAVIT OF APPLICANT

I state that I am the person referred to in this document and that all the information, which I provided above, is true in every respect. I

understand that false or forged statements made in this document in connection with my application for a credential, or failing to

provide relevant information, may be grounds for denial of the application, revocation of the credential granted to me, or criminal

prosecution.

Signature: Date: / /

#2252 (Rev. 11/15)




JOINT COMMISSION CERTIFIED HOSPITAL, FACILITY, AND EMPLOYER VERIFICATION

The State of Wisconsin requests Joint Commission Certified employers to complete this form for all hospitals, facilities, and where the below physician currently has or previously held staff privileges, or employment during the last five (5) years. You must answer all of the following questions and provide any additional information in order for this form to be considered complete.

PHYSICIAN'S NAME:

NAME/LOCATION OF FACILITIES: Please attach a complete list of all facilities where the above physician has had employment or staff privileges under your employment.

JOINT COMMISSION CERTIFIED EMPLOYER NAME:

JOINT COMMISSION CERTIFIED EMPLOYER ADDRESS:

JOINT COMMISSION CERTIFIED EMPLOYER TELEPHONE #: - -

JOINT COMMISSION CERTIFIED EMPLOYER ORGANIZATION NUMBER: Submit your number in the spaces below.

JOINT COMMISSION CERTIFIED EMPLOYER EMAIL ADDRESS: Submit your email address in the spaces below.

YES NO

1. Has your entity received Joint Commission Certified certification?

2. What position does the physician hold under your employment?

3. List the physician’s dates of employment or staff privileges under your employment:

/ / to / /

4. Did the physician either leave your employment in good standing or is currently employed and in good standing? If no, please provide explanation on a separate sheet and attach to this form.

5. Was the physician placed on probation, suspended, or in any way sanctioned or disciplined while at your facility or under your employment? If yes, please provide explanation on a separate sheet and attach to this form.

6. Was the physician granted a leave of absence while employed at any of your facilities or under your employment? If yes, please provide explanation on a separate sheet and attach to this form.

#3046 (Rev. 3/15) Page 1 of 2 Ch. 448, Stats.



YES NO

7. Did this individual have a record of unexcused absences during his/her attendance at any of your facilities or under your employment? If yes, please provide explanation on a separate sheet and attach to this form.

8. Were any restrictions or special requirements placed on this physician's activities that were not placed on all other employees or staff holding similar positions? If yes, please provide explanation on a separate sheet and attach to this form.

9. Were any restrictions placed on this physician’s privileges? If yes, please provide explanation on a separate sheet and attach to this form.

10. Were any formal patient or staff complaints filed against this physician? If yes, please provide explanation on a separate sheet and attach to this form.

11. Was the physician denied hospital privileges while employed by you? If yes, please provide explanation on a separate sheet and attach to this form.

12. Were any incident reports filed involving the professional conduct or behavior of the physician? If yes, please provide explanation on a separate sheet and attach to this form.

13. Was the physician ever subject to non-routine monitoring while at your facility? If yes, please attach explanation on a separate sheet and attach to this form.

14. Was the physician involuntarily removed from a call schedule for cause? If yes, please provide explanation on a separate sheet and attach to this form.

15. Was the physician subject to non-routine quality assessment review? If yes, please provide explanation on a separate sheet and attach to this form.

16. Was the physician the subject of a negative review by a quality assurance or departmental committee? If yes, please provide explanation on a separate sheet and attach to this form.

PRINT NAME AND TITLE OF JOINT COMMISSION CERTIFIED EMPLOYER/OFFICIAL SUPPLYING INFORMATION:

SIGNATURE OF JOINT COMMISSION CERTIFIED EMPLOYER/OFFICIAL SUPPLYING INFORMATION:

___________________________________________________________________________________________________________________

DATE FORM WAS COMPLETED: / /

JOINT COMMISSION CERTIFIED EMPLOYER, RETURN THIS FORM DIRECTLY TO:

DSPS ATTN: Medical Examining Board P.O. Box 8935 Madison, WI 53708-8935

Or you may also fax /email with facility cover sheet /letter to: (608) 261-7083 or [email protected].

#3046 (Rev. 3/15) Page 2 of 2 Ch. 448, Stats.


Uniform Application for Licensure December 2018

Affidavit and Authorization for Release of Information

Applicant: In the presence of a notary public, sign this form with attached photo. If you are using FCVS for credentials verification, consider having that form notarized at the same time. Send the separate notarized FCVS form to FCVS. Do not send this form to FCVS as doing so will delay your licensure.

Send this form to the board you are applying to for licensure. Include all other required materials. A directory of state medical and osteopathic boards is available at: http://www.fsmb.org/contact-a-state-medical-board/.

Please send this form to: Wisconsin Department of Safety and Professional Services P.O. Box 8935 Madison, WI 53708-8935

I, the undersigned, being duly sworn, hereby certify under oath that I am the person named in this application, that all statements I have made or shall make with respect thereto are true, that I am the original and lawful possessor of and person named in the various forms and credentials furnished or to be furnished with respect to my application, and that all documents, forms, or copies thereof furnished or to be furnished with respect to my application are strictly true in every aspect. I acknowledge that I have read and understand the Uniform Application for Physician State Licensure and have answered all questions contained in the application truthfully and completely. I further acknowledge that failure on my part to answer questions truthfully and completely may lead to my being prosecuted under appropriate federal and state laws. I authorize and request every person, hospital, clinic, government agency (local, state, federal, or foreign), court, association, institution, or law enforcement agency having custody or control of any documents, records, and other information pertaining to me to furnish to the Board any such information, including documents, records regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, and to permit the Board or any of its agents or representatives to inspect and make copies of such documents, records, and other information in connection with this application. I hereby release, discharge, and exonerate the Board, its agents or representatives, and any person, hospital, clinic, government agency (local, state, federal, or foreign), court, association, institution, or law enforcement agency having custody or control of any documents, records, and other information pertaining to me of any and all liability of every nature and kind arising out of investigation made by the Board. I will immediately notify the Board in writing of any changes to the answers to any of the questions contained in this application if such a change occurs at any time prior to a license to practice medicine being granted to me by the Board. I understand my failure to answer questions contained in this application truthfully and completely may lead to denial, revocation, or other disciplinary sanction of my license or permit to practice medicine.

NOTARY State of _____________________, County of _____________________,

I certify that on the date set forth below, the individual named above did appear personally before me and that I did identify this applicant by: (a) comparing his/her physical appearance with the photograph on the identifying document presented by the applicant and with the photograph affixed hereto, and (b) comparing the applicant’s signature made in my presence on this form with the signature on his/her identifying document.

The statements on this document are subscribed and sworn to before me by the applicant on this _____ day of ___________, 20____.

Notary Public Signature ____________________________________________ My Notary Commission Expires ______________

Applicant Photograph

Securely tape or glue a recent (per the board’s instructions) front-

view 2” x 2” passport-type color photo of yourself in this square.

_________________________________________________________________________________ Applicant’s signature (must be signed in the presence of a notary)

_________________________________________________________________________________ Applicant’s printed last name, first name, middle initial, and suffix (e.g., Jr.)

_________________________________________________________________________________ Date of signature (must correspond to date of notarization)

[Please note: The Notary Public seal should overlap the bottom of the photo to the left.]

For State Board Use Only

http://www.fsmb.org/contact-a-state-medical-board/


Licensure Verification Form (Form #1)

Applicant: Most boards require verification of each professional license ever held. Refer to the licensure verification resource at https://www.fsmb.org/uniform-application/to determine fees and preferred verification method(s) for each state medical and osteopathic verifying board. You may use this form for each board that requires a written request for verification. In Section 1, list the board you are applying to for licensure, using the directory at https://www.fsmb.org/contact-a-state-medical-board/ to ensure you list the correct name and address. Mail this completed form and any required fee to the verifying board. Verifying Board: Unless using electronic verification, complete Section 2 below and mail this form to the

board at the address listed in Section 1. Use an additional sheet of paper if needed for explanation(s).

Section 1: Applicant Information

First name

Middle name

Last name

Suffix SSN*

Practitioner Type MD DO

Birth date (mm/dd/yyyy)

*The social security number is to be used for purposes of identification only and may not be used for any other reason.

Authorization for Verifying Board: I am applying for a license to practice medicine. The board that I am applying to for licensure requires that this form or an otherwise accepted method of verification be completed by all boards through which I hold or have held licenses, whether now current or not. I authorize the licensing agency of the state/province of

to provide any and all information pertaining to my license number to the board at the address

listed below.

Board name Wisconsin Department of Safety and Professional Services

Mailing address P.O. Box 8935

City/State/Zip Madison, WI 53708-8935

Applicant signature ______________________________________________ Date__________________

Section 2: Board Verification of Licensure

Name of issuing board or license entity

Name of licensee (last, first, middle, suffix)

License type License number __ Issue date Expiration date

1. Is this license current? If not current, please explain: Yes No

2. Have formal disciplinary proceedings been initiated against this applicant’s license by a disciplinary authority in your state? If yes, please explain on a separate sheet of paper and attach it to this form.

Yes No Cannot answer under state law

3. Has the applicant ever been warned, censured, placed on probation, formal consent, reprimand, or in any other manner disciplined, or has the applicant’s license ever been revoked, suspended, or, in any other manner, limited by a licensing or disciplinary authority in your state? If yes, please explain on a separate sheet of paper and attach it to this form.

Yes No

Cannot answer under state law

I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate and complete statement of the record of the

individual named on this form.

Signature

Print name

AFFIX INSTITUTIONAL SEAL HERE Title Date

(If no seal is available, this form must be notarized.) Phone number Fax number

Email

Please mail this completed form and any other items to the board at the address listed in Section 1. Thank you.

Uniform Application for State Licensure December 2018


https://www.fsmb.org/contact-a-state-medical-board/



Medical or Osteopathic School Verification Form (Form #2) Applicant: DO NOT COMPLETE THIS FORM IF YOU ARE USING FCVS. FCVS verifies this data for you. If you are not using FCVS, complete Section 1 below. Send this form and a copy of your medical school diploma to the current dean of your medical or osteopathic school. Copy this form for multiple schools. Dean or Designated Official: Complete Section 2 of this two-page form and certify the enclosed copy of the diploma by placing your school seal on it. Mail the sealed diploma, an official copy of the physician’s transcripts, this completed form, and any other documentation needed to the board at the address listed in Section 1. If transcripts are not in English, an original, certified, and official English translation is required.


First name

Middle name

Last name

Suffix SSN*



Name if different when diploma awarded:

Name of school

*The social security number is to be used for purposes of identification only and may not be used or any other reason.

Waiver for Release of Information: I am applying for a license to practice medicine. I authorize the medical/osteopathic

school listed above to provide any and all information pertaining to my medical/osteopathic education at that institution to

the board at the address listed below. I request that the dean or a designated official complete Section 2 of this form and

seal the copy of my diploma (attached) as described in the instructions above, then mail this completed form, the sealed

diploma copy, and a copy of my official transcripts to the board listed below at the given address:

Board name Wisconsin Department of Safety and Professional Services Mailing address P.O. Box 8935


Applicant signature Date

Section 2: Medical or Osteopathic School Verification

School name

Complete address w/country

School name if different when applicant attended

Hours of undergraduate education required for admission Total weeks of education applicant attended

Attendance (mm/yyyy) from to Graduation date Degree awarded

Unusual Circumstances The following questions apply to unusual circumstances that occurred during any part of the individual’s medical or osteopathic education. Check the appropriate responses and provide dates and requested information. “Yes” responses to any of these questions require a copy of explanatory records or a written explanation attached to this form.

1. Do the official records for this individual reflect interruptions or extensions in his/her medical/osteopathic education? If yes, indicate the reasons for each interruption or extension, the dates of each interruption or extension, and whether each interruption or extension was approved or unapproved.

Yes No

Personal or family

Academic remediation

Health

Financial

Participation in a joint degree program

Participation in a non-research special

study (e.g., fellowship, intl. experience)

Other

From to

From to

From to

From to

From to

From to

From to

Approved Unapproved

Approved Unapproved

Approved Unapproved

Approved Unapproved

Approved Unapproved

Approved Unapproved

Approved Unapproved


2. Do the official records for this individual reflect that he/she was ever placed on academic or disciplinary probation during his/her medical/osteopathic education? If yes, indicate below the reasons for each time of probation and the dates of placement on and removal from probation. Also attach documentation or information of each circumstance and outcome.

Yes No

Academic

Unprofessional conduct

Behavioral reasons

Other

From to

From to

From to

From to

Documentation attached




3. Do the official records for this individual reflect that he/she was ever disciplined for unprofessional conduct/behavioral reasons by the medical/osteopathic school or parent university? If yes, explain below and/or attach documentation or information of each circumstance and outcome.

Yes No

4. Do the official records for this individual reflect that he/she was ever the subject of negative reports

for behavioral reasons or an investigation by the medical/osteopathic school or parent university? If yes, explain below and/or attach documentation or information of each circumstance and outcome.

Yes No

5. Do the official records for this individual reflect that there were ever any limitations or special

requirements imposed on the individual because of questions of academic incompetence, disciplinary problems, or any other reason? If yes, explain below and/or attach documentation or information of each circumstance and outcome.

Yes No

I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate and complete statement of the

record of the individual named on this form.

Signature _

Print name



Email


Uniform Application for Physician Licensure December 2018

Important:

Section 1:

To be completed by the Applicant.

Board Information: To be completed by the applicant.

Applicant Please Sign Here

Institution Name: ___________________________________________ Institution Address: _________________________________________

Affiliated School:

Postgraduate Training Verification Form (Form #3)

1. Did this individual ever take a leave of absence or break from his/her training? -----------------

2. Was this individual ever placed on probation? ------------------------------------------------------------

3. Was this individual ever disciplined or placed under investigation? ---------------------------------

4. Were any negative reports for behavioral reasons ever filed by instructors? ---------------------

5. Were any limitations or special requirements placed upon this individual because of questions of academic incompetence, disciplinary problems or any other reason? -----------------

Yes No

Yes No

Yes No

Yes No

Yes No

Name: _________________________________________ Suffix _____ Practitioner type: M.D. D.O. Date of birth: ____________ (mm/dd/yyyy) SSN* _________________________________________ *The social security number is to be used for purposes of identification only and may not be used for any other reason.

Name if different when diploma awarded: ___________________________________________

Certification: Affix your institutional

seal in this space. If no seal is available, you must have this form notarized.

I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate and complete statement of the record of the individual named on this form. This section MUST be signed by the program director (M.D. or D.O. only). (Signature by personnel other than an M.D. or D.O. must attach an authorization letter. Applicable only for Nevada State Board of Medical Examiners.) Signature:

Print name:

Title:

Email address:

Phone Number: Date:

Use one section per Department/Specialty. If he Department/Specialty is rotating or transitional, please provide a schedule of rotations.

Report Internships, Residencies and Fellowships separately.

If the training level (year) is currently in progress report the expected comple ion date in the "To" field.

Unusual Circumstances: Check the appropriate responses and explain any “Yes” or omitted response(s) on a separate sheet of paper. Attach pages as needed.

Report Incomplete Training Levels (years) separate from those that were successfully completed.

Program Participation :

Section 2 :

Waiver for Release of Information: I request that the program director or a designated official complete Section 2 of this form as outlined below. I authorize the postgraduate training program listed above to provide any all information pertaining to my training there to the board listed below:

Board Name: Wisconsin Department of Safety and Professional Services

Mailing address: P.O. Box 8935. Madison, WI 53708-8935

Applicant Signature ________________________________________ Date _____________

S p e c i a l t y / S u b s pe c i a l t y:

Fr om : / / T o: / /

S u c c es s f u l l y C om pl e t e d ?: Y es N o I n P r o g r e ss Ac cr e d i t e d b y : A C G ME A OA LC G ME RS C C FP C RC P S C A P P A P No n e o f t h e se

Training Level: (e.g., 1, 2, 3, etc.)

Internship

Residency

Chief Residency

Fellowship

Research

Training Level:

(e.g., 1, 2, 3, etc.)

Internship

Residency

Chief Residency

Fellowship

Research

Training Level:

(e.g., 1, 2, 3, etc.)

Internship

Residency

Chief Residency

F e l l o w s h i p

Re s ea r ch

S p e c i a l t y / S u b s pe c i a l t y:

Fr om : / / T o: / /

S u c c es s f u l l y C om pl e t e d ?: Y es N o I n P r o g r e ss Ac cr e d i t e d b y : A C G ME A OA LC G ME RS C C FP C RC P S C A P P A P No n e o f t h e se S p e c i a l t y / S u b s pe c i a l t y:

Fr om : / / T o: / /

S u c c es s f u l l y C om pl e t e d ?: Y es N o I n P r o g r e ss Ac cr e d i t e d b y : A C G ME A OA LC G ME RS C C FP C RC P S C A P P A P No n e o f t h e se

Program Director or designated Official: Please

complete Section 2, and mail this form and any other items to the designated state medical board at the address listed in Section 1. Thank you.

Applicant: Do not complete this form for verification of

accredited training if you are using FCVS. FCVS does not verify non-accredited training. When using FCVS, use this form only if your licensing board requires verification of non-accredited training.


Fifth Pathway Verification Form (Form #4)

Applicant: DO NOT COMPLETE THIS FORM IF YOU ARE USING FCVS. FCVS verifies this data for you.

If you are not using FCVS, complete Section 1 below. Send this form to your Fifth Pathway program director. Program Director or Designated Official: Complete Section 2 of this form. Mail this completed form and

any other documentation (if applicable) to the board at the address listed in Section 1.


First name

Middle name

Last name

Suffix SSN*



Name if different when diploma was awarded:

Name of medical school

*The social security number is to be used for purposes of identification only and may not be used for any other reason.

Waiver for Release of Information: I request that the program director or a designated official complete Section 2 of this form as outlined

above. I authorize the designated official to provide any and all information pertaining to my time there to the board listed below:

Board name Wisconsin Department of Safety and Professional Services

Mailing address P.O. Box 8935


Applicant signature

Date

Section 2: Fifth Pathway Verification

Institution name Affiliated school _

Institution name if different when applicant attended

Institution address w/country

Type of Clinical Rotation From To Weeks Credit

__ _

_

_

_

Completed? Yes. Attendance was from to . Completion date was .

No. Withdrawal* date was . *If the applicant withdrew or was dismissed, please explain below.

No. Dismissal* date was . *If the applicant withdrew or was dismissed, please explain below

I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate and complete statement of the record of the

individual named on this form.

Signature

Print name



Email


Uniform Application for State Licensure December 2018

Documents

Wisconsin Department of Safety and Professional Services · WI Department of Safety and Professional Services, Medical Examining Board Uniform Application Instructions December 2018