Applicant: In the presence of a notary public, sign this form with attached photo.
Send this form to:
Oklahoma State Board of Podiatric Medical Examiners
101 NE 51st Street
Oklahoma City, OK 73105
I, the undersigned, being duly sworn, hereby certify under oath that I am the person named in this application, that all statements I havemade or shall make with respect thereto are true, that I am the original and lawful possessor of and personal named in the various forms
and credentials furnished with respect to my application, and that all documents, forms, or copies thereof furnished or to be furnished withrespect to my application are strictly true in every aspect.
I acknowledge that I have read and understand the application and have answered all questions contained in the application truthfully andcompletely. 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 orlaw enforcement agency having custody or control of any documents, records, and other information pertaining to me to furnish to theBoard any such information, including documents, records regarding charges or complaints filed against me, formal or informal, pendingor 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 theBoard.
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 achange occurs at any time prior to a license to practice 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 otherdisciplinary sanction of my license or permit to practice.

Applicant Photograph
Securely tape or glue a
recent front view 2”x2”
passport-type color photoof yourself in this square

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

Applicants printed last name, first name, middle initial, and suffix (e.g., Jr.)

Date of signature (must correspond to the date of notarization)[Please note: The Notary Public seal should overlap the bottom of the photo to the left]
NOTARY
State of, County ofI certify that on the date set forth below, the individual named above did appear personally before me and that I did identify this applicantby (a) comparing his/her physical appearance with the photograph on the identifying document presented by the applicant and with thephotograph affixed hereto, and (b) comparing the applicant’s signature made by my presence on this form with the signature on his/heridentifying document.
The statements on this document are subscribed and sworn to before me by the applicant on thisNotary Public Signature

day ofMy Notary Commission Expires, 20