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Get Oklahoma Verification Of Clinical Clerkship Form

FORM 4 MD Oklahoma State Board of Medical Licensure and Supervision P. O. Box 18256 Oklahoma City OK 73154-0256 VERIFICATION OF CLINICAL CLERKSHIP In the event a foreign medical school utilized clerkships in the United States its territories or possessions and the applicant graduated from medical school after July 1 2003 such clerkships shall have been performed in hospitals and schools that have programs accredited by the Accreditation Council for Graduate Medical Education ACGME. One form must be completed and mailed directly to the Board for each clerkship* This is to certify that Student s Name / / U*S* Social Security Number Date of Birth Medical School Completed a clerkship offered by Name of Facility Address of Facility From Month Day Year through in the clinical area Clinical Area This facility has programs that are accredited by ACGME in the areas of. Specialty instructor for the student named above during the clerkship indicated and that I have carefully read and completed this form and that the statements made herein are accurate. Institution Seal Type or Print Name of Facility Program Director or Instructor Address City State Telephone Number Zip Code Signature In the absence of an official institution seal the Facility Program Director or Instructor s signature must be notarized* Signed and sworn before me this day of Month Year. One form must be completed and mailed directly to the Board for each clerkship* This is to certify that Student s Name / / U*S* Social Security Number Date of Birth Medical School Completed a clerkship offered by Name of Facility Address of Facility From Month Day Year through in the clinical area Clinical Area This facility has programs that are accredited by ACGME in the areas of. Specialty instructor for the student named above during the clerkship indicated and that I have carefully read and completed this form and that the statements made herein are accurate. Specialty instructor for the student named above during the clerkship indicated and that I have carefully read and completed this form and that the statements made herein are accurate. Institution Seal Type or Print Name of Facility Program Director or Instructor Address City State Telephone Number Zip Code Signature In the absence of an official institution seal the Facility Program Director or Instructor s signature must be notarized* Signed and sworn before me this day of Month Year. One form must be completed and mailed directly to the Board for each clerkship* This is to certify that Student s Name / / U*S* Social Security Number Date of Birth Medical School Completed a clerkship offered by Name of Facility Address of Facility From Month Day Year through in the clinical area Clinical Area This facility has programs that are accredited by ACGME in the areas of. Specialty instructor for the student named above during the clerkship indicated and that I have carefully read and completed this form and that the statements made herein are accurate. Institution Seal Type or Print Name of Facility Program Director or Instructor Address City State Telephone Number Zip Code Signature In the absence of an official institution seal the Facility Program Director or Instructor s signature must be notarized* Signed and sworn before me this day of Month Year.

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