OKLAHOMA STATE BOARD OF PODIATRIC MEDICAL EXAMINERSAPPLICATION FOR LICENSURE
PLEASE PRINT OR TYPE ALL QUESTIONSLAST NAMESOCIAL SECURITY #FIRST NAMEDATE OF BIRTH

MIDDLE NAME

PLACE OF BIRTH

SUFFIX (ex. JR, SR, II, III)

COUNTRY

PLEASE LIST ALL MAIDEN, PREVIOUS NAMES AND/OR ALIASES

MAILING ADDRESSSEXCITYSTATERACEZIP CODECOUNTRYMALE Caucasian Black

 American Indian HispanicFEMALE Other

CELL #HOME #OFFICE #FAX #EMAILPLEASE LIST ALL THE STATES IN WHICH YOU CURRENTLY OR PREVIOUSLY HELD A LICENSE TO PRACTICE
STATE

LIC #STATE

LIC #STATE

LIC #STATE

LIC #STATE

LIC #STATE

LIC #Have you taken the National Board of Podiatric Medical Examiners Examination?
Status:  PENDING
 DIPLOMATEINFORMATION BELOW IS FOR OFFICE USE ONLY – DO NOT COMPLETEDATE APPLICATION RECEIVED

LICENSE NUMBER

DATE FEE RECEIVEDAMOUNT PAIDDATE APPROVEDDATE LICENSE ISSUED

 YES

 NO

NAME

ANSWER THE FOLLOWING QUESTIONS – ALL YES ANSWERS MUST INCLUDE A NOTARIZED STATEMENT OF FULL EXPLANATIONA.

Have you ever been denied provider participation, terminated, sanctioned, or penalized by any
third party payor, to include TRICARE, MEDICARE, MEDICAID?

 YES

 NOB.

Have you ever voluntarily surrendered or had any adverse action taken against any narcotic
permit (state or federal)?

 YES

 NO

C.

Have you been denied membership or had disciplinary action taken by a state or county
podiatric society?

 YES

 NO

D.

Have you ever been denied, had removed, or suspended hospital or staff privileges?

 YES

 NO

E.

Have you ever surrendered hospital staff privileges while under investigation or to avoidinvestigation?

 YES

 NOF.

Have you ever entered into an agreement with a federal, state or local jurisdictional body toavoid formal action?

 YES

 NOG.

Have you ever been the subject of an investigation, probation, or disciplinary action by ahospital, clinic, practice group, training program, or professional school?

 YES

 NO

H.

Have you had any adverse judgment, settlement, or award against you arising from a
professional liability claim?

 YES

 NOI.

Have you ever had professional liability coverage declined, canceled, issued on special terms, orrenewal refused?

 YES

 NOJ.

Have you ever been reported to the National Practitioners Data Bank (NPDB)?

 YES

 NOK.

Has your application for examination or licensure ever been rejected in this or any other state?

 YES

 NOL.

Have you ever failed an examination for licensure? If so, how many times?

 YES

 NO

M.

Have you ever surrendered a license or had a license revoked?

 YES

 NON.

Has you ever been the subject of disciplinary action by a licensing agency?

 YES

 NOO.

Have you ever been charged with or convicted of a felony or misdemeanor, other than trafficviolations?

 YES

 NOP.

Have you been charged with or convicted of a crime directly or indirectly related to yourpractice of Podiatry?

 YES

 NOQ.

Have you been arrested, charged with, or convicted of a traffic violation involving the use of any
drug or chemical substance, including alcohol?

 YES

 NO

R.

Are you now or have you ever been addicted to or used in excess, any drug or chemicalsubstance, including alcohol?

 YES

 NO

S.

Have you obtained an assessment for or been treated for the use of any drug or chemical
substance, including alcohol?

 YES

 NOT.

Do you currently have or have you had any emotional, mental, or physical disorder which, if
untreated, could affect your ability to practice competently?

 YES

 NO

NAME
PLEASE COMPLETE ALL EDUCATION BELOW (POST GRADUATE TRAINING IS ON THE NEXT PAGE)
HIGH SCHOOL
CITY

STATE

MO/YR ENTERED/COUNTRY
MO/YR COMPLETED/DEGREE AWARDED

COLLEGE
CITY

STATE

MO/YR ENTERED/COUNTRY
MO/YR COMPLETED/

DEGREE AWARDED

COLLEGECITY

STATEMO/YR ENTERED/COUNTRY
MO/YR COMPLETED/DEGREE AWARDED

COLLEGECITYSTATE

MO/YR ENTERED/COUNTRY
MO/YR COMPLETED/DEGREE AWARDED

COLLEGECITY
MO/YR ENTEREDDEGREE AWARDED

STATE/COUNTRY
MO/YR COMPLETED/NAME
POST GRADUATE TRAININGPER LAW/RULE – REQUIRES SATISFACTORY COMPLETION OF 3 YEAR PODIATRIC SURGICAL RESIDENCY FOR LICENSURE
HOSPITALCITY
MO/YR ENTEREDSTATE/COUNTRY
MO/YR COMPLETED/SPECIALTYHOSPITALCITY
MO/YR ENTEREDSTATE/COUNTRY
MO/YR COMPLETED/SPECIALTYHOSPITALCITY
MO/YR ENTEREDSTATE/COUNTRY
MO/YR COMPLETED/SPECIALTYHOSPITALCITY
MO/YR ENTEREDSTATE/COUNTRY
MO/YR COMPLETED/SPECIALTYHOSPITALCITY
MO/YR ENTEREDSPECIALTY

STATE/COUNTRY
MO/YR COMPLETED/NAME
PRACTICE HISTORY AND NON-MEDICAL ACTIVITIES (DO NOT INCLUDE TRAINING) – ACCOUNT FOR ALL TIME WITH NO
GAPS MORE THAN 90 DAYS
MO/YR START/CITY

MO/YR START/////CITY

MO/YR END

MO/YR END

MO/YR END/MO/YR END/MO/YR END
STATE

EMPLOYER/ACTIVITYJOB TITLE/EMPLOYER/ACTIVITYJOB TITLE/EMPLOYER/ACTIVITYJOB TITLE/STATE/EMPLOYER/ACTIVITYJOB TITLE

STATECITY

MO/YR START/STATECITY

MO/YR START

MO/YR ENDEMPLOYER/ACTIVITYJOB TITLE

STATECITY

MO/YR START/STATECITY

MO/YR START

MO/YR ENDEMPLOYER/ACTIVITYJOB TITLE

STATECITY

MO/YR START/STATECITY

MO/YR START

MO/YR ENDEMPLOYER/ACTIVITYJOB TITLE/EMPLOYER/ACTIVITYJOB TITLE

NAMECURRENT PRACTICEADDRESSPHONE NUMBERCITYSTATEZIPFAX NUMBERI ATTEST THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGESIGNATURE

PLEASE INCLUDE $200 APPLICATION FEE AND THESE ORIGINAL DOCUMENTS WITH THIS APPLICATION:EVIDENCE OF STATUSAPPLICATION INSTRUCTIONSPHOTO/OATHNOTARIZED STATEMENT FOR “YES” ANSWERS
MAIL TO:OKLAHOMA STATE BOARD OF PODIATRIC MEDICAL EXAMINERS101 NE 51ST STREETOKLAHOMA CITY, OK 73105
ADDITIONALLY, THESE DOCUMENTS ARE TO BE COMPLETED AND MUST BE SENT DIRECTLY FROM THESOURCE
FORM 1 (MEDICAL SCHOOL)
FORM 2 (POST GRADUATE TRAINING – FOR EACH PROGRAM)FORM 5 (CURRENT TRAINING PROGRAM) – IF APPLICABLE
FORM 3/LETTER FROM EACH STATE VERIFYING LICENSURE (PAST OR PRESENT)VERIFICATION OF NATIONAL BOARD OF PODIATRIC EXAMINERS
FINALLY, YOU MUST COMPLETE THE EXTENDED BACKGROUND CHECK – OUR OFFICES WILL RETRIEVE THESEDIRECTLY FROM TRAK-1ONCE YOUR APPLICATION IS RECEIVED AND PROCESSED, YOU WILL RECEIVE AN EMAIL CONTAINING ALETTER WITH YOUR DEFICIENCIES AS WELL AS A LOGIN FOR YOU TO “TRACK” THE STATUS OF YOURAPPLICATION.
SHOULD YOU HAVE ANY ADDITIONAL QUESTIONS, PLEASE EMAIL LICENSING@OKMEDICALBOARD.ORG