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This guide provides a comprehensive overview of how to complete the Application for a Limited License to Participate in a Postgraduate Training Program in Podiatric Medicine. Through clear, step-by-step instructions, users can navigate the form easily and effectively.

Follow the steps to complete the application form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by typing or clearly printing all required information in the designated fields. Make sure to provide your Social Security number, as it is mandatory for processing your application.
3. Attach one recent passport-quality photograph of yourself in the specified area provided in the application.
4. Fill out your personal information, including your full name, current address, permanent address (if different), date of birth, place of birth, and email address. Ensure accuracy in spelling and formatting.
5. Complete the pre-professional education section by entering the name of the school, location, and dates attended for your medical training.
6. If applicable, provide details for the Doctor of Podiatric Medicine degree and the school from which it was granted, including location and dates attended.
7. Respond to all questions regarding disciplinary actions, license denials, treatment for substance abuse, hospital privileges, and malpractice history. If necessary, provide a signed and notarized statement to explain any affirmative answers.
8. Sign and date the application in the affirmation section to attest that all statements are true and complete.
9. In the authorization for release of information section, sign and date again to allow the Professional Licensing Agency to obtain pertinent information.
10. Complete the postgraduate training verification section by ensuring it is filled out by the appropriate hospital or institution personnel and notarized.
11. After completing all sections of the form, review all information for accuracy, save your changes, and then you may download, print, or share the completed form as required.

Complete your application online to expedite your licensing process.