Free 27521.FH11 - Indiana

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APPLICATION FOR PODIATRY LICENSE
State Form 27521 (R10 / 2-06) Approved by State Board of Accounts, 2006

INDIANA BOARD OF PODIATRIC MEDICINE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2064 E-mail: [email protected]

* Social Security number is required pursuant to I.C. 4-1-8-1. FOR OFFICE USE ONLY
License / Exam fee Receipt number License issuance date (month, day, year) Date fee paid (month, day, year) License number Temporary number

Applicant Attach two (2) passport type quality photographs of yourself taken within the last eight weeks. Please sign each photo at the bottom. Negative and Polaroids are not acceptable.

APPLICANT INFORMATION
Name of applicant (last, first, middle) Address (number and street or rural route number) City, state, and ZIP code Daytime telephone number Evening telephone number Email address Place of birth * Social Security number

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Date of birth (month, day, year)

BASIS FOR LICENSURE

BASIS FOR LICENSURE PLEASE CHECK ONE BOX BELOW

Examination You are applying to take the NBPME Part III exam in Indiana. Endorsement of Examination You have passed the NBPME Part III exam, you meet all other requirements for examination but you have not practiced podiatry for at least five (5) years in another state. Endorsement You have passed the NBPME Part III exam, you meet all other requirements for examination and you have practiced podiatry for at least five (5) years in another state.

Do you desire a temporary permit?

Yes

No

Name of malpractice insurance carrier:

NAME OF SCHOOL

PRE-PROFESSIONAL EDUCATION LOCATION

DATES ATTENDED

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PODIATRIC EDUCATION YEAR
1st 2nd 3rd 4th 5th

NAME OF SCHOOL

LOCATION

DATES ATTENDED

PODIATRIC DEGREE GRANTED BY
Name of school Location Date of graduation (month, day, year)

List all Postgraduate Training, include all Preceptorships, Residencies and Fellowships. LOCATION NAME OF HOSPITAL

DATES: FROM
(month / year)

TO

Do you hold or have you ever held a license, certificate, registration or permit to practice any regulated health occupations? List all states, including Indiana, in which you have been licensed to practice any regulated health occupation. NUMBER DATE ISSUED TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR PERMIT

Yes

No

STATE

CURRENT STATUS

List all places of employment since graduation. Endorsement candidates must submit proof of at least five years of employment. NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES

DATE

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List all places you have lived since graduation. GENERAL LOCATION

DATE

If your answer is "Yes" to any of the following, explain fully in a sworn affidavit, including all related details, include the violation, location, date and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice podiatric medicine or any regulated health occupation in any state (including Indiana) or country? 3. Are you now, or have you ever been, treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty or nolo contendere to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug additions? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 6. Have you ever been admonished, censored, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties or perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any or its authorized representatives in connection with processing my application for podiatric licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Board from any and all liability in connection with such disclosures. A photostatic copy or this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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