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Get OR OMB Verification Of Practice Employment Staff Membership MD/DO/DPM Licensure 2015

Ergency room, etc. where employed or where hospital staff membership has been requested. Source is to complete LOWER portion of the form and return DIRECTLY to the OREGON MEDICAL BOARD. Last Name First Name Other Names you have been known by Middle Name Date of Birth (mm/dd/yy) Hospital, Clinic, Facility name at the time of association Type of Association: Employee Other: Staff Member Last 4 Digits of Social Security Number Dates of Association: FROM (mm/dd/yy) Locum Tenens Emergency.

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