Name: Last

     

First

     

Middle

     

Suffix (Jr, Sr)

     

List all names under which you have ever been known:

     

Social Security Number

     

Driver’s License # and Issuing State

     

E-mail Address

     

Marital Status

     

Spouse’s Full Name

     

Cell Phone #

     

Sex

     

Height

     

Weight

     

Eyes

     

Hair

     

Race

     

Physical Marks

     

Home Address

(mailing address)

Street & Number

     

City

     

State

     

Zip

     

Parish (if in LA)

     

Telephone (area code)

     

Preferred Mailing

(if other than above)

Street & Number

     

City

     

State

     

Zip

     

Parish (if in LA)

     

Telephone (area code)

     

Business Address

(this is the public

address and

will be posted on

LSBME website)

Street & Number

     

City

     

State

     

Zip

     

Parish (if in LA)

     

Telephone (area code)

     

Date of Birth      

Place of Birth      

Are you a U.S. citizen?      

If not a native born U.S. citizen, provide the following information:

If naturalized: Certificate number      

INS number      

Petition number      

Date issued      

District court through which issued      

If immigrant: Type of Visa      

U.S. Active Duty

Yes No

Branch

     

Dates Served

     

Type of Discharge

     

High School

     

College/University

     

City, State

     

City, State

     

Mo/Yr Started

     

Mo/Yr Graduated

     

Mo/Yr Started

     

Mo/Yr Ended

     

Degree Earned

     

College/University

     

College/University

     

City, State

     

City, State

     

Mo/Yr Started

     

Mo/Yr Ended

     

Degree Earned

     

Mo/Yr Started

     

Mo/Yr Ended

     

Degree Earned

     

Professional/Medical School

     

Hospital/Program

     

City, State & Country if not in the U.S.

     

City, State & Country if not in the U.S.

     

Mo/Yr Started

     

Mo/Yr Ended

     

Degree

     

Mo/Yr Started

     

Mo/Yr Ended

     

Specialty

     

Account for all time for the ten years preceding your application including any periods of unemployment

From

Month/Year

To

Month/Year

Location

City/State

Employer

Specialty/Activity

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Name (Printed or typed):       SS#:      

Yes

No

1

In the 5 years prior to this application have you had any physical injury or disease or mental illness or impairment, which could reasonably be expected to affect your ability to practice medicine or other health profession? You may answer no to this question if you are currently in the Physicians' Health Foundation of Louisiana and in good standing.

2

In the 5 years prior to this application have you been referred to or obtained treatment for a substance abuse disorder including alcohol abuse? You may answer no to this question if you are currently in the Physicians' Health Foundation of Louisiana and in good standing.

3

Have you been cited, arrested, charged with, convicted of or pled guilty or nolo contendere to a violation of any municipal, state or federal statute including any that have been expunged or judicially removed for any reason with the exception of misdemeanor traffic offenses or traffic ordinance violations that do NOT involve the use of drugs or alcohol?

4

Has your application for any professional license, certificate, or registration been denied by any state licensing board or federal authority?

5

Has your professional license, certificate, or registration been the subject of investigation or revoked, suspended, probated, restricted, reprimanded, limited, or subjected to any other disciplinary action by any state licensing board or federal authority?

6

Have you voluntarily surrendered any professional license, or agreed with any licensing authority not to seek re-licensure in order to avoid disciplinary action, investigation or inquiry?

7

Was your application for staff or clinical privileges at any hospital, clinic, or other health care institution denied?

8

Were you the subject of an inquiry or investigation by any hospital, clinic, or other health care institution which resulted in the suspension, restriction, probation or other limitation on your affiliation or staff or clinical privileges; including remediation and/or non-disciplinary sanctions?

9

Did you surrender or fail to renew staff or clinical privileges at any hospital, clinic, or other health care entity in lieu of investigation, while under investigation or while you were the subject of disciplinary proceedings?

10

Were you the subject of disciplinary action, placed on academic probation, or asked to undergo additional training or remediation during your professional training (as a student, intern, resident, fellow, or other trainee)?

11

Did you leave any professional training program as defined above before completion?

12

Was your professional training program extended for any reason?

13

Has your participation in any private, federal or state health insurance program been terminated, non-renewed, denied, suspended, restricted, placed on probation, or are you the subject of a current investigation or proceeding by such entities?

14

Have you surrendered your state or federal controlled substances permit or registration?

15

Has your membership in a professional society been revoked, suspended, or disciplined or have you resigned membership while under investigation

16

In the 10 years prior to this application have any malpractice claims been settled by you or on your behalf?

17

Has any court determined you are currently in violation of a court’s judgment or order for the support of dependent children?

Section 1: To Applicant

Download and fill in your name and SSN above. Complete Section 1 before a Notary. Forward this form to your Dean/Registrar for completion.

Recent photograph

Passport quality photograph of Applicant securely affixed. 2” x 2” clear, front view, full face without hat or dark glasses. Full-length photograph, black and white or computer-generated will not be accepted. Applicant is to sign name across bottom of photograph, partly on photograph and partly upon the page.

Notary is to affix seal directly on photograph.

Affix Photograph

Here

(Follow directions carefully.)

I certify that the photograph is a true likeness of

____________________________________________ (Applicant).

On this the ___________Day of ____________________, ________________

____________________________________________________

Notary Public

My commission expires_________________________________

Section 2: To Dean/Registrar

After completion of this form, return to Office of Licensure, Louisiana State Board of Medical Examiners, P. O. Box 30250, New Orleans, LA 70190-0250. DO NOT RETURN TO APPLICANT.

I hereby certify that ________________________________________________________________________________

Whose photograph appears above, was awarded the Masters degree in Clinical Pharmacology

Dated _________________ from this school.

_______________________________________ ___________________________________________

Name of school/program Signature of Dean/Registrar

____________________________________ _________________________________________

Address Title

__________________________________________

Date

Affix School Seal Here

Section 1: To Applicant

Complete Section 1 before a Notary. Forward this form to the DoD Psychopharmacology Training Director

Recent photograph

Passport quality photograph of Applicant securely affixed. 2” x 2” clear, front view, full face without hat or dark glasses. Full-length photograph, black and white or computer-generated will not be accepted. Applicant is to sign name across bottom of photograph, partly on photograph and partly upon the page.

Notary is to affix seal directly on photograph.

Affix Photograph

Here

(Follow directions carefully.)

I certify that the photograph is a true likeness of ____________________________________________ (Applicant).

On this the ___________Day of ________________, _________

____________________________________________________

Notary Public

My commission expires_________________________________

Section 2: To DoD-PDP Training Director

After completion of this form, return to Office of Licensure, Louisiana State Board of Medical Examiners, P. O. Box 30250, New Orleans, LA 70190-0250. DO NOT RETURN TO APPLICANT.

I hereby certify that ________________________________________________________________________________

Whose photograph appears above, successfully completed the Psychopharmacology Training in the DOD (NOT DoD-PDP)

Dated _________________

A certified copy of the certificate of completion and a detailed description of the training is attached

_______________________________________ ___________________________________________

Training Director – Print Name of program

____________________________________ ___________________________________________

Training Director – Title Address 1

_____________________________________ ___________________________________________

Training Director Sign (no stamps) Address 2

_______________________________________ ___________________________________________

Telephone Street

___________________________________________

City/ State/ Zip

Section 1: To Applicant

Complete Section 1 before a Notary. Forward this form to the DoD-PDP Training Director

Recent photograph

Passport quality photograph of Applicant securely affixed. 2” x 2” clear, front view, full face without hat or dark glasses. Full-length photograph, black and white or computer-generated will not be accepted. Applicant is to sign name across bottom of photograph, partly on photograph and partly upon the page.

Notary is to affix seal directly on photograph.

Affix Photograph

Here

(Follow directions carefully.)

I certify that the photograph is a true likeness of ____________________________________________ (Applicant).

On this the ___________Day of ________________, ____________

____________________________________________________

Notary Public

My commission expires_________________________________

Section 1: To Applicant: Download this form and fill in your name and address as it appears on your examination application form.

Name: (Last, First, Middle)

     

Address: (Number, Street, Apartment #) (City, State, Zip Code + 4)

     

     

Social Security Number:

      -      -      

Section 2: To American Psychological Association College of Professional Psychology from the Applicant:

Gentlemen:

I am applying for licensure as a medical psychologist in the state of Louisiana. This is your authorization to release all my examination results on the Psychopharmacology Examination for Psychologists (PEP) (on file and future examination results), favorable or otherwise, to the Louisiana State Board of Medical Examiners. See Section 3 below.

__________________________________________________ ___________________________

(Signature) (Date)

Section 3: To American Psychological Association College of Professional Psychology from the Board

Please mail examination results to: Louisiana State Board of Medical Examiners, Licensure Division, P. O. Box 30250, New Orleans, LA 70190-0250. DO NOT mail to Applicant. The LSBME will NOT accept this information from any source other than from you.