Loading
Form preview picture

Get CA 07A-100 L6 2013-2024

Acgme. org/adspublic Program Verified Specialty OFFICIAL CERTIFICATION I certify that I am the program director or clinical instructor and that the applicant named above satisfactorily completed the above named clinical clerkship and I hereby declare under penalty of perjury under the laws of the State of California that the above statements are true and correct. PRINT NAME OF PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR SIGNATURE OF PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR Signature Stamp Is Not Acceptable Email Address DATE Signature Date Phone Number ATTENTION THE PERSON WHO SIGNS THIS FORM MAY NOT BE RELATED TO THE APPLICANT BY BLOOD MARRIAGE OR ADOPTION. Only the Program Director or clinical instructor may sign this form. If that signature authority is being delegated to another person evidence of that delegation must be attached to this form may be a photocopy. BUSINESS CONSUMER SERVICES AND HOUSING AGENCY - Department of Consumer Affairs EDMUND G. BROWN JR. Governor MEDICAL BOARD OF CALIFORNIA Licensing Program Certificate of Individual Clinical Clerkship Training This form is required of international medical school graduates who completed any clinical training outside of the primary teaching hospital of their medical school. A separate form is to be used for each clinical clerkship. Type or Print Legibly NAME Last Date of Birth mm/dd/yyyy MBC Use Only APPLICANT INFORMATION First Middle U.S. Social Security Number Medical School of Graduation Personal Data PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR TO COMPLETE CLERKSHIP INFORMATION Facility Name Facility Address Clinical Specialty Dates of Completion mm/dd/yyyy Start Date / / End Date / / This facility is formally affiliated or has a formal contract of affiliation with a U.S. Canadian or Yes No International Medical School. Name of the U.S. Canadian or International Medical School. If affiliated This facility does have an ACGME-accredited residency training program. ACGME 10-digit program http //www. acgme. org/adspublic Program Verified Specialty OFFICIAL CERTIFICATION I certify that I am the program director or clinical instructor and that the applicant named above satisfactorily completed the above named clinical clerkship and I hereby declare under penalty of perjury under the laws of the State of California that the above statements are true and correct. PRINT NAME OF PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR SIGNATURE OF PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR Signature Stamp Is Not Acceptable Email Address DATE Signature Date Phone Number ATTENTION THE PERSON WHO SIGNS THIS FORM MAY NOT BE RELATED TO THE APPLICANT BY BLOOD MARRIAGE OR ADOPTION* Only the Program Director or clinical instructor may sign this form* If that signature authority is being delegated to another person evidence of that delegation must be attached to this form may be a photocopy. Such delegation must be on official letterhead and must be dated within the last 12 months. NOTE If a hospital seal is not available the program director or clinical instructor shall also sign in the section below in the presence of a notary public* Signature of Program Director or Clinical Instructor State of County of Subscribed and sworn to or affirmed before me on this day of 20 Notary Seal Printed name of Program Director or Clinical Instructor to be the person who appeared before me. .

How It Works

07A-100 rating
4.9Satisfied
481 votes

Tips on how to fill out, edit and sign Affirmed online

How to fill out and sign Licensing online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The days of terrifying complex tax and legal documents are over. With US Legal Forms the process of creating official documents is anxiety-free. The leading editor is directly at your fingertips giving you multiple advantageous instruments for completing a CA 07A-100 L6. The following tips, with the editor will help you through the entire process.

  1. Click on the Get Form option to start editing.
  2. Switch on the Wizard mode on the top toolbar to get more recommendations.
  3. Fill out every fillable field.
  4. Make sure the data you fill in CA 07A-100 L6 is up-to-date and correct.
  5. Add the date to the record with the Date function.
  6. Click on the Sign tool and create a digital signature. You can find three available options; typing, drawing, or capturing one.
  7. Make sure that each and every field has been filled in properly.
  8. Select Done in the top right corne to export the record. There are various options for receiving the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

We make completing any CA 07A-100 L6 more straightforward. Start now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing edmund

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to CA 07A-100 L6

  • L6
  • 2012
  • 07A-100
  • legibly
  • edmund
  • 10-digit
  • xx
  • clerkship
  • affirmed
  • delegated
  • Evergreen
  • Licensing
  • satisfactorily
  • photocopy
  • subscribed
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.