Postgraduate Training Authorization Letter PTAL
ApplicationLicensing Program 2005 Evergreen Street, Suite 1200
MEDICAL BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
APPLICATION INFORMATION FOR A POSTGRADUATE TRAINING AUTHORIZATION
LETTER (PTAL)
A Postgraduate Training Authorization Letter (PTAL) allows you to
seek and commence ACGME accredited training in California.
MINIMUM REQUIREMENTS TO APPLY FOR A PTAL
To be eligible for a Postgraduate Training Authorization Letter
(PTAL), applicants must have received all of their medical school
education from and graduated from a medical school recognized or
approved by the Medical Board of California (Board). The medical
school's name must exactly match the name on the Board's list of
recognized medical schools. Prior to submitting an application,
please refer to the Board’s website to verify your medical school
is recognized:
http://www.mbc.ca.gov/Applicants/Medical_Schools/Schools_Recognized.aspx
Disclosure of your United States Social Security Number (SSN) or
your Individual Taxpayer Identification Number (ITIN) is mandatory
prior to the issuance of a PTAL. Section 30 of the Business and
Professions Code authorizes collection of your SSN or ITIN. Section
31(e) of the Business and Professions Code allows the State Board
of Equalization and the Franchise Tax Board to share taxpayer
information with the Board. A license issued by the Board may be
suspended if a state tax obligation is not paid. Reporting a number
on your Application that is not your SSN or ITIN may be grounds for
denial of licensure. To meet the examination requirement for a
PTAL, you must have taken and passed all components of USMLE Steps
1 and 2 per Section 1328 of Title 16 California Code of
Regulations. Certification by the Educational Council for Foreign
Medical Graduates (ECFMG) is required. To obtain further
information regarding ECFMG Certification, please refer to their
website at www.ecfmg.org.
GENERAL INFORMATION
As an applicant, you personally are responsible for all information
disclosed on your Application, Forms L1A-L1F, including any
responses that may have been completed on your behalf by others. An
application may be denied based upon omission, falsification or
misrepresentation of any item or response on the application or any
attachment. The Medical Board of California considers violations of
an ethical nature to be a serious breach of professional conduct.
Processing Times: Application materials are processed in the date
order in which the application is received. All application forms
and supporting materials are stamped with the date and time
received in the office. Generally, you should anticipate receiving
written correspondence confirming the status of the application for
a PTAL within 60 days of submission of the application.
07A-100 (Revised 6/2018)
GENERAL INFORMATION (Continued)
FCVS: The Federation Credentials Verification Service (FCVS) is
operated by the Federation of State Medical Boards of the United
States, Inc. The Medical Board of California (Board) offers this
link to FCVS as a convenience to our applicants. You may learn more
about FCVS at: http://www.fsmb.org/licensure/fcvs/.
The Board does not mandate that you use the FCVS. FCVS is NOT a
requirement for filing a Physician’s and Surgeon’s Application. You
will be required to complete the Board’s application and provide
all necessary supporting documentation. As part of your
application, you may request FCVS to submit directly to the Board
your Medical Professional Information Profile. We will review the
information provided along with our application and determine on an
individual basis the items that we will accept from FCVS.
NotaryCam: NotaryCam is a company that provides an online notary
service that is valid in California and may be used on our
Application forms. The Board does not mandate that you use this
online service. The Board is providing this information as a
convenience to its applicants. You may obtain further information
regarding this online notary service at:
https://www.notarycam.com/.
Certified Electronic Diploma (CeDiploma®): CeCredential Trust® is a
company that provides an alternative to a paper diploma and is
accepted by the Medical Board of California. The Board does not
mandate that you use this online service. If you were not issued a
CeDiploma by your medical school, please contact your school
directly. The Board is providing this information as a convenience
to its applicants. You may obtain further information regarding
this electronic diploma service at the following website:
https://www.cecredentialtrust.com.
Fingerprints: Applicants who reside in California must complete the
electronic Live Scan fingerprint process. You will need to use the
Request for Live Scan Service form that may be obtained from the
Board’s website. Please refer to the following website for Live
Scan facilities in California:
http://ag.ca.gov/fingerprints/publications/contact.php.
Applicants residing outside California must submit two completed
fingerprint cards or have your fingerprints completed at a
California Live Scan facility.
Criminal Records Check from both the California Department of
Justice and the Federal Bureau of Investigation must be received
prior to the issuance of a PTAL.
Convictions: Note that convictions adjudicated in juvenile courts
or convictions two years or older under Health and Safety Code
sections 11357(b), (c), (d), (e) or section 11360(b) need not be
reported. Convictions expunged or set aside pursuant to section
1203.4 of the California Penal Code or equivalent non-California
law MUST be disclosed. If in doubt as to whether a conviction
should be disclosed, it is best to disclose the conviction (see the
Criminal Record History section on the Application).
Grounds for Denial: Each applicant’s credentials for licensure in
California are reviewed on an individual basis. The Board has the
authority to deny licensure based upon an applicant’s act of
dishonesty, unprofessional conduct, conviction of a crime,
discipline of another state license, or inability to practice
medicine safely.
Due Diligence: Pursuant to Section 1306 of Title 16 California Code
of Regulations, an application shall be deemed abandoned if an
applicant fails to complete the application process within 365 days
from the date of written notification from the Board of the
documents needed to complete the application.
PTAL Information – Page 2
PTAL APPLICATION CHECKLIST
Listed below are the minimum application and supporting materials
required for an international medical school graduate to obtain a
PTAL. This list is not all-inclusive as additional items may be
necessary based on responses provided on your Application or
information obtained from other entities.
Application, Fees, and Fingerprints
Application Fee $491 The Application fee is non-refundable. Refer
to the Fee Schedule for further details.
Application For Physician’s and Surgeon’s License, Forms
L1A-L1F
Complete all fields, answer all questions and have the application
notarized. All six pages must be submitted together.
Fingerprints:
Two (2) Fingerprint Cards
Applicants who reside in California must complete the electronic
Live Scan fingerprint process. You will need to use the Request for
Live Scan Service form that may be obtained from the Board’s
website. Mail a copy of the completed form with your
Application.
Applicants residing outside California must submit two completed
fingerprint cards or have your fingerprints completed at a
California Live Scan facility. Fingerprint cards will be mailed to
you once the Board receives your application and appropriate
processing fees. All personal data must be completed on the
fingerprint cards or the cards will be returned for
completion.
Criminal Records Check from both the California Department of
Justice and the Federal Bureau of Investigation must be received
prior to the issuance of a PTAL.
Examination Documentation
ECFMG Certification Status Report
A Certification Status Report from the Educational Council for
Foreign Medical Graduates (ECFMG) is required to verify your
certification is valid. You may obtain further information from
their website at www.ecfmg.org. The ECFMG must mail the
Certification Status Report directly to the Board to be
acceptable.
Official Examination Scores from the Federation of State Medical
Boards (FSMB)
Certified Transcripts of Scores from FSMB to verify your passing
scores on Steps 1 and 2 (CK and CS) of the USMLE. The transcript
may be requested from the Federation’s website at
http://www.fsmb.org/licensure/usmle-step-3/transcripts. The FSMB
must send the transcript directly to the Board to be
acceptable.
Medical Education Documentation
Certificate of Medical Education, Form L2
A Certificate of Medical Education, Form L2, is required from each
medical school attended. Complete the applicant information at the
top of the form and mail it to your medical school. The form will
need to be completed, signed and dated by the school official and
affixed with the official medical school seal. Any fields or
questions left unanswered will require completion of a new form.
The Form L2 must be mailed directly from the medical school to the
Board to be acceptable.
PTAL Information – Page 3
Medical Education Documentation (continued)
Official Medical School Transcript
An original official medical school transcript and translation (if
not in English), prepared on university letterhead affixed with the
signature of the dean or registrar and the medical school seal,
documenting all of the basic science and clinical courses completed
during the medical curriculum is required. A transcript is required
from each medical school attended. The transcript must be mailed
directly from the medical school to the Board to be
acceptable.
Certified Copy of Medical School Diploma
A certified copy of your medical school diploma is required. The
certified copy must have the original signature of the dean or
registrar of the medical school, be affixed with the official
medical school seal, and include a statement attesting that the
copy is a true and correct copy of the original. The certified copy
of your diploma must be mailed directly from the medical school to
the Board to be acceptable.
Certified English Translations (if applicable)
Certified English translations are required for all academic
documents that are not prepared in the English language. Refer to
the Translation of International Academic Credentials for details
regarding acceptable translations. The certified translation must
be mailed directly to the Board to be acceptable.
Certificate of Clinical Training, Form L5
A Certificate of Clinical Training, Form L5, is required to report
all undergraduate clinical clerkships. Complete the applicant
information at the top of the form and mail it to your medical
school. The form will need to be completed, signed and dated by the
school official and affixed with the official medical school seal.
You may print or copy as many forms as necessary to provide a
complete breakdown of your undergraduate clinical training. The
Form(s) L5 must be mailed directly from the medical school to the
Board to be acceptable.
For your information, the pertinent portions of Section 2089.5 of
the Business and Professions Code require:
“(b) Instruction in the clinical courses shall total a minimum of
72 weeks in length.
(c) Instruction in the core clinical courses of surgery, medicine,
family medicine, pediatrics, obstetrics and gynecology, and
psychiatry shall total a minimum of 40 weeks in length with a
minimum of eight weeks instruction in surgery, eight weeks in
medicine, six weeks in pediatrics, six weeks in obstetrics and
gynecology, a minimum of four weeks in family medicine, and four
weeks in psychiatry.”
Please refer to our website at www.mbc.ca.gov to obtain a complete
copy of Section 2089.5 of the Business and Professions Code.
PTAL Information – Page 4
Medical Education Documentation (continued)
Certificate of Individual Clinical Clerkship Training, Form L6 (if
applicable)
Certificate of Individual Clinical Clerkship Training, Form L6, is
required for each undergraduate clinical clerkship completed
outside of the primary teaching hospital of the medical school of
attendance. The form must be submitted to the hospital where the
clerkship was completed and the current program director or
clinical instructor must verify completion of the clerkship. The
form may not be signed and dated prior to the end date of the
clerkship. The completed Form(s) L6 must be submitted directly from
the facility to the Board to be acceptable. If the hospital where
an undergraduate clinical rotation was completed is now closed, the
medical school may provide a certified copy of the student
evaluation form that was initially completed by the sponsoring
hospital. The copy must be affixed with the medical school seal and
signature of the dean certifying it is a true copy of the original
document and mailed directly to the Board. For your information,
only undergraduate clinical clerkships meeting the criteria
specified in Section 2089.5 of the Business and Professions Code
will be used to satisfy the required 72 weeks of clinical
clerkships.
Other Items
Curriculum Vitae (CV) Please submit a signed and dated current CV
with your Application.
Timeline of Activities
A complete timeline from the graduation of medical school to
present is required. Provide the Board with a written chronological
description of all your professional and non-professional
activities with no gaps.
If you have completed any externships, observerships, or volunteer
activities in California, please include a detailed description of
your duties and responsibilities along with the location and name
of the supervising physician.
Mail your signed and dated Timeline of Activities form directly to
the Board.
Explanation to Application Question (if applicable)
This form may be used to provide a detailed written explanation for
a “yes” response to a question on the Application. Please use a
separate form for each positive response. The form can be obtained
from the Board’s website.
Additional Information Once formally admitted to an
ACGME-accredited postgraduate training program, you must complete
and
return the Postgraduate Training Registration Form which may be
obtained from the Board’s website.
The PTAL is valid for one year from the date of issuance. You are
required to update your file on a yearly basis by completing the
Application, Forms L1A-F. Check the update box at the top of the
form and include your file number. No additional fees are required.
You must mail in the Update Application along with a current
Timeline of Activities form. An Update Application may not be
submitted using the BreEZe online application system.
Section 2066 of the Business and Professions Code allows
international medical school graduates to engage in three years of
ACGME-accredited postgraduate training without a license. You must
be licensed at the end of the three year period or all clinical
service in California facilities must cease. The Board includes all
accredited training in the United States or Canada to calculate the
maximum three years of training.
PTAL Information – Page 5
O F C A L I F O R N I A MEDICAL BOARD Licensing Program
2005 Evergreen Street, Suite 1200 Sacramento, CA 95815-5401
Phone: (916) 263-2382 Fax: (916) 263-2487 www.mbc.ca.gov Protecting
consumers by advancing high quality, safe medical care.
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
FEE SCHEDULE Application for Physician's and Surgeon's
License
or Postgraduate Training Authorization Letter (PTAL)
PART 1: APPLICATION FEE The application fee includes a required
fingerprint processing fee. Please note, the application will not
be reviewed until the required application fee is received.
Total Non-Refundable Application Fee Required
PART 2: LICENSE FEE
License fees are required prior to issuance of your medical
license. To reduce delays in issuing a license, you may submit the
application and license fees together.
Initial License Fee ($808.00) or Reduced Initial License Fee
($416.50) – If you currently are enrolled in an ACGME/RCPSC
accredited training program, you may be eligible for the reduced
initial licensing fee. To verify your enrollment, you will need to
submit a Certificate of Current Postgraduate Training, Form
L4.
The license fee includes a mandatory $25 fee for the Steven M.
Thompson Physician Corps Loan Repayment Program.
NOTE: PTAL applicants are not required to submit the initial
license fees until all licensing requirements have been met.
Initial License Fee or
Reduced Initial License Fee
$416.50 PART 3: SONG-BROWN FAMILY PHYSICIAN TRAINING ACT The
Song-Brown Health Care Workforce Training Act (Song-Brown Program)
was established to increase the number of family physicians to
provide needed medical services to the people of California. The
program encourages universities and primary care health
professionals to provide healthcare in medically underserved areas,
and provides financial support to family medicine, internal
medicine, OB/GYN, and pediatric residency programs, family nurse
practitioner, physician assistant, and registered nurse education
programs throughout California. For further information regarding
the program, please visit the Office of Statewide Health Planning
and Development (OSHPD) website at
https://oshpd.ca.gov/loans-scholarships-grants/grants/song-brown/.
You may voluntarily contribute any amount (minimum $25.00) to the
Song-Brown Program. The Board transfers all funds collected on a
monthly basis to OSHPD.
Voluntary $25.00 (minimum)
PART 4: TOTAL AMOUNT
Certified Check, Cashier's Check, Money Order, or Personal Check
made payable to:
MEDICAL BOARD OF CALIFORNIA
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
LIVE SCAN INFORMATION California’s Department of Justice (DOJ)
provides statewide Live Scan, which is an electronic fingerprinting
system with a subsequent automated background check and response.
This system significantly expedites the fingerprint clearance
process. APPLICANTS WHO RESIDE IN CALIFORNIA MUST COMPLETE THE
ELECTRONIC LIVE SCAN FINGERPRINT PROCESS. Applicants residing
outside of California may choose this option if visiting the
state.
• CALIFORNIA DOES NOT HAVE LIVE SCAN LINKS TO ANY OTHER STATES
•
The “Request For Live Scan Service” form (below) is required to
have your fingerprints processed by Live Scan. This form must be
completed in triplicate; therefore, THREE copies will be printed
automatically when printing the form. Please ensure that all
personal data (name, AKA’s, date of birth, sex, height, weight, eye
color, hair color, place of birth, Social Security Number or
Individual Taxpayer Identification Number, California driver’s
license number and home address) is provided on each of the three
forms. The last section of the form requires information from the
fingerprint agency; please ensure this information is completed or
the forms will be void. It is the responsibility of the applicant
to ensure that the person scanning the fingerprints submits TWO
digital prints, one for the DOJ and one for the FBI.
Applicants can access the website,
http://ag.ca.gov/fingerprints/publications/contact.htm to obtain
the names and location of approved fingerprint sites. Information
pertaining to the need for appointments, hours of availability, and
rolling fees are also available through that website. After
completing the Live Scan process, applicants must submit ONE of the
THREE forms with the initial application to document the scanning
of their fingerprints. The results of Live Scan fingerprints are
generally received within five (5) days.
Applicants residing outside of California must submit two completed
fingerprint cards or have your fingerprints completed at a
California Live Scan facility. The results of paper fingerprint
cards are generally received within six (6) weeks.
Whether you use Live Scan or paper fingerprint cards, you will be
charged an administrative fee by the local agency that scans the
prints or provides the inked impressions. This is in addition to
the fingerprint processing fee that must be paid to the Medical
Board of California with your application. For further information
about the fingerprint clearance process and time frames, please
visit the following website at:
http://ag.ca.gov/consumers/morefaqs.php
Because applicants from the medical professions must be concerned
with sanitary issues, they wash and scrub their hands so much that
images of their fingerprints are often difficult to read. When the
impressions are of such poor quality that they cannot be searched
in DOJ’s fingerprint data base, the fingerprints (whether Live Scan
or paper card) are rejected and reprints will be necessary.
Therefore, please advise the person processing your fingerprints
that extra care needs to be given to ensure that clear impressions
have been made.
Criminal Records Check from both the California Department of
Justice and the Federal Bureau of Investigation must be received
prior to the issuance of a Postgraduate Training Authorization
Letter (PTAL) or a Physician’s and Surgeon’s medical license.
NOTE: If you have ever been convicted of a misdemeanor or felony,
the record of conviction will be reported to the Board as a result
of your fingerprint inquiry.
07A-100 (Revised 01/2019)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
Type of License/Certification/Permit OR Working Title (Maximum 30
characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code
(five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school
submissions)
City State ZIP Code
Other Name (AKA or Alias) Last First Suffix
Date of Birth Sex Male Female Driver's License Number
Height Weight Eye Color Hair Color
Place of Birth (State or Country) Social Security Number
Billing Number
Misc. Number
(Agency Billing Number)
(Other Identification Number)
Home Address Street Address or P.O. Box City State ZIP Code
Your Number: OCA Number (Agency Identifying Number)
Level of Service: DOJ FBI
If re-submission, list original ATI number: (Must provide proof of
rejection)
Original ATI Number
Employer Name Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY
(if needed) - Requesting Agency
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 (orig. 04/2001;
rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
Type of License/Certification/Permit OR Working Title (Maximum 30
characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code
(five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school
submissions)
City State ZIP Code
Other Name (AKA or Alias) Last First Suffix
Date of Birth Sex Male Female Driver's License Number
Height Weight Eye Color Hair Color
Place of Birth (State or Country) Social Security Number
Billing Number
Misc. Number
(Agency Billing Number)
(Other Identification Number)
Home Address Street Address or P.O. Box City State ZIP Code
Your Number: OCA Number (Agency Identifying Number)
Level of Service: DOJ FBI
If re-submission, list original ATI number: (Must provide proof of
rejection)
Original ATI Number
Employer Name Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY
(if needed) - Requesting Agency
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 (orig. 04/2001;
rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
Type of License/Certification/Permit OR Working Title (Maximum 30
characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code
(five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school
submissions)
City State ZIP Code
Other Name (AKA or Alias) Last First Suffix
Date of Birth Sex Male Female Driver's License Number
Height Weight Eye Color Hair Color
Place of Birth (State or Country) Social Security Number
Billing Number
Misc. Number
(Agency Billing Number)
(Other Identification Number)
Home Address Street Address or P.O. Box City State ZIP Code
Your Number: OCA Number (Agency Identifying Number)
Level of Service: DOJ FBI
If re-submission, list original ATI number: (Must provide proof of
rejection)
Original ATI Number
Employer Name Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY
(if needed) - Requesting Agency
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
TRANSLATION OF INTERNATIONAL ACADEMIC CREDENTIALS For the Board to
accurately evaluate compliance with California requirements, any
applicant with non-English, international academic credentials must
provide certified translations of those original transcripts and
academic documents. These must be original, official certified
translations. Photocopies are not acceptable. When requesting
official transcripts and academic documents, an applicant whose
education was completed at an institution in a bilingual country,
where English is one of the official languages, may be able to
avoid the necessity of arranging for a translation by asking the
school to generate an English-language version of the
transcript.
Applicants may also request their medical school to provide
original, official, literal word-for-word, certified translations
of their official transcripts and academic documents. The Board
will consider medical school translations prepared on the official
school letterhead with the translator’s original declaration, and
the translator’s signature and title.
Each translator must provide an original signed declaration with
each translation attesting to his/her fluency in the particular
language and certifying under penalty of perjury that the
translation is complete and accurate to the best of the
translator’s ability and knowledge. Each translation must be
accompanied by a copy of the corresponding non-English document.
The official certified translation must be mailed directly from the
translator to the Board to be acceptable.
Translators who prepare translations may not be related to an
applicant by blood, marriage, or adoption. Translations that are
signed on behalf of the official translator are not acceptable; the
translator who prepares the translation must provide the signed
declaration. Translations without an official letterhead will not
be accepted.
The Board recommends, but does not require, that applicants with
non-English academic credentials use one of the following sources
for translation:
Translator accredited by the American Translators Association
(ATA): The ATA accredits individual translators by examination.
Although accreditation is available only to individuals, ATA
membership includes not only individuals but companies that employ
accredited translators. The translator who prepares the translation
must sign the translation and declaration in the presence of a
Notary Public, unless the translation is a service provided by a
known translation agency which affixes the document with its own
official seal. ATA membership includes accredited translators
residing in the U.S., Canada, Mexico, and overseas. Although the
ATA does not make referrals, a listing of accredited translators
and member companies is available through its website at
http://www.atanet.org./. The ATA may be reached by phone at
703-683-6100 or by e-mail at
[email protected].
1. Certified or registered court interpreter: Some state court
systems offer examinations for certification or registration of
court interpreters. In California, the Judicial Council is charged
with these functions. Information on court interpreters is
available through the Judicial Council at 415-865-4200. General
information is available via its website,
http://www.courts.ca.gov./. The Judicial Council has contracted
with Cooperative Personnel Services (CPS) for examination and
certification of Certified Administrative Hearing and Medical
Interpreters. A master list of these interpreters is available at
the CPS website, www.courts.ca.gov/3796.htm. The court interpreter
must sign the translation and declaration in the presence of a
Notary Public. Applicants residing outside California but within
the United States may call the National Center for State Courts at
800-616-6164 for information on certification and registration of
interpreters in other states.
Other authorized translators the Board will consider include: (1) a
commercial translation agency with its own business letterhead and
official agency seal or notary public seal; (2) the Chairman of the
Department of Foreign or Classical Languages of a U.S. university
(prepared on original school letterhead); or (3) a consulate of the
U.S. Embassy with bilingual translators available.
NOTE: The official certified translation must be mailed directly
from the medical school or from the translator to the Board to be
acceptable.
07A-100 Revised 01/2019
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
APPLICATION TYPE OF APPLICATION MBC
Use Only
Application Type
U.S. or Canadian Medical School Graduate International Medical
School Graduate
(Check All That Apply) Physician’s and Surgeon’s License
Postgraduate Training Authorization Letter (PTAL) Update
Application: File # Limited Practice License
PRIORITY REVIEW & EXPEDITED LICENSURE Honorably Discharged
Veterans of the Armed Forces - Must supply satisfactory evidence to
the Board that you have served as an active duty member of the
Armed Forces of the United States and were honorably
discharged.
Practice in Medically Underserved Area or Population - Must supply
satisfactory evidence to the Board that you have accepted
employment and intend to practice in an area of California formally
designated as an underserved area or underserved population. Please
see further details on our website at
http://www.mbc.ca.gov/Applicants/Physicians_and_Surgeons/Underserved.aspx.
Temporary License for Spouse of Active Duty Member of the Armed
Forces - Must supply satisfactory evidence to the Board that you
are married to, or in a domestic partnership or other legal union
with, an active duty member of the Armed Forces of the United
States who is assigned to a duty station in California under
official active duty military orders. In addition, you must meet
the requirements listed in Business and Professions Code Section
115.6.
Type or Print Legibly PERSONAL INFORMATION
1. Legal Name Last First Middle Suffix
2. Other Names/Alias
3. United States Social Security Number (SSN) or Individual
Taxpayer Identification Number (ITIN)
SSN ITIN
4. Date of Birth (mm/dd/yyyy) 5. Gender Male Female
6. Address of Record This address will be used for all current
correspondence during the review process and will be posted on the
Board’s website upon issuance of a license.
If you are using a P.O. Box please list a confidential street
address below.
Mailing Address (40 characters maximum per line, including
spaces)
Mailing Address continued (40 characters maximum per line,
including spaces)
City State/Province Zip/Postal Code Country
Confidential Address (Only required if Address of Record is a P.O.
Box)
7. Telephone Numbers
Home # Work # Cell #
8. E-mail Address (Required)
9. Have you served or are you currently serving in the military?
Yes No
10. Are you requesting expediting of this application as a spouse
or domestic partner of an active duty member of the Armed Forces?
Yes No
MBC Use Only
07A-100 (Revised 01/2019)
APPLICANT: DATE OF BIRTH: (Print Legal Name) (mm/dd/yyyy)
PREVIOUS APPLICATION OR LICENSE NOTE: A “yes” response to question
11 requires a signed and dated written explanation. The
Explanation For Application Question form may be used to provide
your explanation. 11. Have you ever filed an application for a
Physician’s and Surgeon’s License Yes No or a PTAL in California
that has been withdrawn, abandoned, or denied? 12. Have you
previously held a Physician’s and Surgeon’s License in
California?
Yes No If yes, please provide license number: ______________
Expired: _____________
EXAMINATIONS 13. Are you certified by the Educational Commission
for Foreign Medical Graduates? Yes No
14. List all of the following examinations you have taken and
USMLE, FLEX, NBME, LMCC and/or passed: STATE BOARDS
Examination Date Passed
MEDICAL EDUCATION NOTE: To be eligible for a PTAL or License, all
schools attended must be on the Board’s list of recognized or
approved medical schools. If you did not attend or graduate from a
recognized or approved medical school, you may be eligible for
licensure pursuant to Section 2135.7 of the Business and
Professions Code. To view the Board’s list of recognized or
approved medical schools, please refer to our website at:
http://www.mbc.ca.gov/Applicants/Medical_Schools/Schools_Recognized.aspx.
15. List each medical school that you have attended and the medical
school of graduation.
Medical School Name Mailing Address Dates of Attendance
(mm/dd/yyyy)
Start
End
Start
End
Start
End
Medical School of Graduation Title of Degree Awarded Issue Date of
Degree (mm/dd/yyyy)
MBC Use Only
16. Have you participated in any ACGME-accredited postgraduate
training programs in the United States or RCPSC-accredited
postgraduate training in Canada?
(If NO, please skip to question #24)
Yes No
List every program (internship, residency and fellowship) in which
you have participated or are currently participating, regardless of
whether the program was completed or any credit was granted.
(Use the Addendum to Question #16 Form if additional space is
needed)
Facility Name City, State/Province Specialty Dates of Training
(mm/dd/yyyy)
Start
End
Start
End
Start
End
NOTE: A “yes” response to question 17-23 requires a signed and
dated written explanation. The Explanation For Application Question
form may be used to provide your explanation.
17. Have you ever received partial or no credit for a postgraduate
training program? Yes No
18. Have you ever taken a leave of absence or break from your
training? Yes No
19. Have you ever been terminated, dismissed or expelled from a
program? Yes No
20. Have you ever been placed on probation for any reason? Yes
No
21. Have you ever been disciplined or placed under investigation?
Yes No
22. Have you ever had any limitations or special requirements
placed upon you for clinical performance, professionalism, medical
knowledge, discipline, or for any other reason?
Yes No
23. Have you ever had a postgraduate training program contract not
be renewed or offered for a following year? Yes No
MEDICAL LICENSE 24. Have you ever held or do you currently hold a
medical license in any U.S. state,
U.S. territory, or Canadian province? Yes No
List medical license information for all licenses ever held below.
Do not list temporary, training, or provisional licenses. (Use the
Addendum to Question #24 Form if additional space is needed.)
U.S. State, U.S. Territory or Canadian Province License Number
Dates of Practice
(mm/yyyy to mm/yyyy)
ABMS CERTIFICATION 25. Are you currently certified by a Member
Board of the American Board of
Medical Specialties? Yes No
MALPRACTICE HISTORY 26. Has a claim or an action ever been filed
against you for the practice of medicine Yes No that resulted in a
malpractice settlement, judgment, or arbitration?
DISCIPLINARY HISTORY These questions refer to discipline by any
hospital, Military or Public Health Service, State Board, or other
Governmental Agency of any U.S. state, U.S. territory, Canadian
province, or foreign country.
27. Have you ever had your DEA privileges denied, suspended,
restricted, or terminated? Yes No
28. Have you ever entered into any arrangement, agreement or plea
in lieu of federal prosecution with the DEA to resolve an alleged
violation of a federal or state drug statute or regulation?
Yes No
29. Have you ever withdrawn an application for medical licensure in
lieu of denial, disciplinary action, or for any other similar
reason? Yes No
30. Have you ever been denied a license to practice medicine? Yes
No
31. Is any denial pending against you? Yes No
32. Have you ever had any license to practice medicine subjected to
any disciplinary action? Yes No
33. Is any disciplinary action pending against any of your licenses
to practice medicine? Yes No
34. Have you ever surrendered a license to practice medicine? Yes
No
35. Have you ever had any license to practice medicine revoked,
suspended, or placed on probation? Yes No
36. Have you ever had any license to practice medicine subjected to
any action including, but not limited to, informal or confidential
discipline, consent orders, letters of warning, letters of
reprimand, or citation?
Yes No
37. Have you ever been charged with, or been found to have
committed unprofessional conduct, professional incompetence, gross
negligence, or repeated negligent acts by any medical licensing
board or hospital?
Yes No
38. Have you ever resigned from a medical staff in lieu of
disciplinary or administrative action? Yes No
39. Is any disciplinary action pending against your hospital or
staff privileges? Yes No
40. Have you ever had staff privileges in a hospital terminated,
denied, suspended, limited, revoked, or not renewed? Yes No
41. Have you ever had any healing arts license or certificate
disciplined by another state or federal territory? Yes No
NOTE: A “yes” response to question 26-41 requires a signed and
dated written explanation. The Explanation For Application Question
form may be used to provide your explanation. L1D
07A-100 (Revised 01/2019)
07A-100 (Revised 06/2018)
Name & DOB
Criminal History
CRIMINAL RECORD HISTORY Applicants who answer “NO” to the questions
below, but have a previous conviction or plea, may have their
application denied for knowingly falsifying the application. If in
doubt as to whether a conviction should be disclosed, it is best to
disclose the conviction on the application.
For each conviction, you must submit certified copies of the
arresting agency report, certified copies of the court documents
(court docket) and a signed and dated descriptive explanation of
the circumstances surrounding the conviction (i.e., dates and
location of the incident and all circumstances surrounding the
incident). If the documents were purged by the arresting agency
and/or court, a letter of explanation from these agencies is
required. In addition, you may submit evidence of
rehabilitation.
42. Have you ever been convicted of, or pled guilty or nolo
contendere to ANY offense in the United States, its territories, or
a foreign country? This includes every citation, infraction,
misdemeanor and/or felony, including traffic violations.
Convictions that were adjudicated in the juvenile court or
convictions under California Health and Safety Code sections
11357(b), (c), (d), (e), or section 11360(b) which are two years or
older should NOT be reported. Convictions that were later expunged
from the record of the court or set aside pursuant to section
1203.4 of the California Penal Code or equivalent non-California
law MUST be disclosed.
Yes No
43. Exclusive of juvenile court adjudications and criminal charges
dismissed under section 1000.3 of the California Penal Code or
equivalent non-California laws, or convictions under California
Health and Safety Code section 11357(b), (c), (d), (e), or section
11360(b) which are two years or older, have you had a charge or
conviction that was set aside or later expunged from the record of
the court?
Yes No
44. Is any criminal action pending against you, or are you
currently awaiting judgment and sentencing following entry of a
plea or jury verdict? Yes No
45. Are you a registered sex offender? Yes No
Limitations
PRACTICE IMPAIRMENT OR LIMITATIONS An affirmative answer to any of
the questions below will require the Board to make an
individualized assessment of the nature, the severity and the
duration of the risks associated with an ongoing medical condition
to determine whether an unrestricted license should be issued,
whether conditions should be imposed, or whether you are eligible
for licensure. Please note that a Limited Practice License may be
available. Refer to the Application Information for a Limited
Practice License for further information.
47. Have you ever been treated for or had a recurrence of a
diagnosed addictive disorder? Yes No
48. Have you ever been diagnosed with an emotional, mental, or
behavioral disorder that may impair your ability to practice
medicine safely? Yes No
49. Have you ever been diagnosed with a neurological or other
physical condition that may impair your ability to practice
medicine safely? Yes No
50. Do you have any other condition that may in any way impair or
limit your ability to practice medicine safely? Yes No
51. Do you suffer from a progressive disorder or a health condition
that will likely result in a general decline in health or function
that may impair or limit your ability to practice medicine
safely?
Yes No
NOTE: A “yes” response to question 42-51 requires a signed and
dated written explanation. The Explanation For Application Question
form may be used to provide your explanation. L1E
PHOTOGRAPH MBC Use Only
Notice: All items in this application are mandatory. Failure to
Photograph provide any of the requested information will delay the
processing Affix a 2” X 2” Photo Here of your application. The
information provided will be used to Photo Must Be Recent and
Must Be of your Head and determine your qualifications for
licensing per Section 2080 of the Shoulder Areas Only California
Business and Professions Code, which authorizes the Altered
Photographs collection of this information. The information on your
application are NOT Acceptable may be transferred to other medical
licensing authorities, the
Federation of State Medical Boards, or other governmental law
enforcement agencies. You have the right to review your application
subject to the provisions of the Information Practices Act. The
Chief of the Licensing Program is the custodian of records.
Rev L1A-F Staff Initials
DECLARATION The applicant,
_______________________________________________________________,
____________________,
PRINT LEGAL NAME (First, Middle, Last, Suffix) DATE OF BIRTH
(mm/dd/yyyy)
being first duly sworn upon his/her oath deposes and says: that I
am the person herein named subscribing to this application; that I
have read the complete application, know the full content thereof,
and declare under penalty of perjury, that all of the information
contained herein and evidence or other credentials submitted
herewith are true and correct; that I am the lawful holder of the
degree of Doctor of Medicine as prescribed by this application,
that the same was procured in the regular course of instruction and
examination, and that it, together with all the credentials
submitted, were procured without fraud or misrepresentation or any
mistake of which I am aware and that I am the lawful holder
thereof. Further, I hereby authorize all hospitals, institutions or
organizations, my references, personal physicians, employers (past,
present and future), or business and professional associates (past,
present, and future), and all government agencies (local, state,
federal, or foreign) to release to the Medical Board of California
or its successors any information, files or records, including
medical records, educational records, and records of psychiatric
treatment and treatment for drug, alcohol and/or substance abuse or
dependency, requested by that Board in connection with this
application; or any further or future investigation by that Board
necessary to determine any medical competence, professional
conduct, or physical or mental ability to safely engage in the
practice of medicine. I further authorize the Medical Board of
California or its successors to release, in any investigation or
proceeding, to the organizations, individuals or groups listed
above any information which is material to this application or any
subsequent licensure.
I UNDERSTAND THAT ANY OMISSION, FALSIFICATION OR MISREPRESENTATION
OF ANY ITEM OR RESPONSE ON THIS APPLICATION OR ANY ATTACHMENT
HERETO IS A SUFFICIENT BASIS FOR DENYING OR REVOKING A
LICENSE.
SIGN LEGAL
NAME:__________________________________________DATE:________________________
NOTARY SECTION
SIGNATURE OF APPLICANT:
__________________________________________________________ (SIGN
LEGAL NAME IN THE PRESENCE OF NOTARY)
A notary public or other officer completing this certificate
verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document.
State of _________________________
County of _________________________
Subscribed and sworn to (or affirmed) before me on this ________
day of _________________, 20_____,
by, _________________________________________ proved to me on the
basis of satisfactory evidence (PRINT APPLICANT’S LEGAL NAME)
NOTARY SEAL to be the person who appeared before me.
SIGNATURE OF NOTARY PUBLIC
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
EXPLANATION FOR APPLICATION QUESTION This form may be used to
provide a detailed written explanation for a “yes” response to a
question on the Application. Please use as many forms as necessary
to provide a detailed explanation. A separate form is to be used
for each question.
Type or Print Legibly PERSONAL INFORMATION Last First Middle
SuffixLEGAL NAME:
Date of Birth (mm/dd/yyyy) U.S. SSN or ITIN Medical School of
Graduation
DETAILED WRITTEN EXPLANATION
SIGN LEGAL NAME: DATE:
07A-100 (Revised 01/2019)
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
TIMELINE OF ACTIVITIES A complete timeline of activities from
graduation of medical school to present is required. Provide the
Board with a written chronological description of all your
professional and non-professional activities. Please include a
detailed description of your duties and responsibilities for any
externship, observership, or volunteer activity in California.
Dates shall be reported in chronological order in month/year
(mm/yyyy) format. Please use as many forms as necessary to provide
a complete timeline of activities.
Type or Print Legibly PERSONAL INFORMATION Last First Middle
SuffixLEGAL NAME:
Date of Birth (mm/dd/yyyy) U.S. SSN or ITIN Medical School of
Graduation
Start Date
End Date
Activities MBC Use
07A-100 (Revised 01/2019)
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
CERTIFICATE OF MEDICAL EDUCATION Check one: U.S. or Canadian
Medical School Graduate International Medical School Graduate Type
or Print Legibly APPLICANT INFORMATION MBC Use
Only
LEGAL NAME: Last First Middle Suffix
Date of Birth (mm/dd/yyyy) Last 4 Digits of U.S. SSN or ITIN
Medical School of Graduation
MEDICAL SCHOOL: PLEASE COMPLETE THIS FORM IN THE ENGLISH LANGUAGE
NOTE: If the applicant had an accelerated or extended curriculum,
withdrew from this institution, or was accepted with advanced
standing, a letter of explanation from a school official is
required. The letter must be on medical school letterhead, signed
by a school official, and be mailed directly to the Board from the
medical school.
1. Name of Medical School
2. State/Province/Country 3. The undersigned further certifies that
the records of this institution show that the applicant attended in
this institution
____________ years of resident instruction, completing at least
4,000 hours, of which at least 80 percent actual attendance is
required in the subjects set forth hereunder (Business and
Professions Code Sections 2089, 2089.5, 2089.7, 2090, 2091.1,
2091.2). Alcoholism and Chemical Dependency Anatomy Anesthesia
Biochemistry Child Abuse Detection and Treatment Dermatology
Embryology Family Medicine*
Geriatric Medicine Histology Human Sexuality Medicine Neuroanatomy
Neurology Obstetrics and Gynecology Ophthalmology
Otolaryngology Pain Management and End-of-Life-Care** Pathology,
Bacteriology, and Immunology Pediatrics Pharmacology Physical
Medicine Physiology Preventative Medicine, including
Nutrition
Psychiatry Radiology, including Radiation Safety Spousal Partner
Abuse Detection &
Treatment*** Surgery, including Orthopedic Surgery Therapeutics
Tropical Medicine Urology
*ONLY applicable to medical students who enrolled in medical school
on or after May 1, 1998 **ONLY applicable to medical students who
enrolled in medical school on or after June 1, 2000
***ONLY applicable to medical students who enrolled in medical
school on or after September 1, 1994
4. Did the applicant withdraw or transfer from this medical school?
Yes No
5. What is the standard duration of the curriculum at this
institution? years
6. Date the applicant was enrolled in medical school?
(mm/dd/yyyy)
7. Date the applicant was issued the diploma of Bachelor/Doctor of
Medicine (mm/dd/yyyy)
UNUSUAL CIRCUMSTANCES DURING MEDICAL SCHOOL Any “Yes” response
below requires a signed and dated letter of explanation by school
official. Unusual
Circumstances
8. Did this applicant ever take a leave of absence from his/her
medical education? Yes No
9. Was this applicant ever placed on probation? Yes No
10. Was this applicant ever disciplined or placed under
investigation? Yes No 11. Were any limitations or special
requirements imposed on this applicant because of
questions of academic or disciplinary problems, or for any other
reason? Yes No
MEDICAL SCHOOL OFFICIAL CERTIFICATION AFFIX MEDICAL SCHOOL
SEAL
I certify that I am the President, Dean, or Registrar and hereby
declare under penalty of perjury under the laws of the State of
California that the above statements are true and correct.
_________________________________________
_____________________________ PRINTED NAME OF SCHOOL OFFICIAL TITLE
OF SCHOOL OFFICIAL
_________________________________________
_____________________________ SIGNATURE OF SCHOOL OFFICIAL
DATE
Attention Medical School: THE PERSON WHO SIGNS THIS FORM MAY NOT BE
RELATED TO THE APPLICANT BY BLOOD, MARRIAGE OR ADOPTION. Only the
President, Dean, or Registrar may sign this form. If the signature
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.
School Seal
Initials & Date
NOTE: The completed form must be mailed directly from the medical
school to the Board to be acceptable. 07A-100 (Revised
01/2019)
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
CERTIFICATE OF COMPLETION OF ACGME/RCPSC POSTGRADUATE TRAINING To
be completed by the facility for every medical school graduate
completing postgraduate training in the United States or
Canada.
Check one: U.S. or Canadian Medical School Graduate International
Medical School Graduate
Type or Print Legibly APPLICANT INFORMATION MBC Use Only
Applicant Information
Last First Middle Suffix LEGAL NAME:
Date of Birth (mm/dd/yyyy) Last 4 Digits of U.S. SSN or ITIN
Medical School of Graduation
PROGRAM DIRECTOR TO COMPLETE ACGME OR RCPSC TRAINING INFORMATION
Facility Name
Facility Address
Dates of Training (mm/dd/yyyy)
Start Date: End Date (or anticipated completion date):
UNUSUAL CIRCUMSTANCES Program Director: Please provide a signed and
dated letter of explanation, including dates, for any “yes”
response to questions # 1-7. The explanation must be provided on
program letterhead and mailed directly to the Board with the Form
L3A-L3B.
1. Did the applicant receive partial or no credit during his/her
postgraduate training? Yes No
2. Did the applicant ever take a leave of absence or break from
his/her training? Yes No
3. Was the applicant ever terminated, dismissed or expelled? Yes
No
4. Was the applicant ever placed on probation? Yes No
5. Was the applicant ever disciplined or placed under
investigation? Yes No
6. Were any limitations or special requirements placed upon the
applicant for clinical performance, professionalism, medical
knowledge, discipline, or for any other reason? Yes No
7. Did the program decline to renew or offer the applicant
postgraduate training program contract for a following year? Yes
No
GENERAL MEDICINE TRAINING REQUIREMENT 8. Did the applicant complete
a minimum of four months of general medicine as part of
this postgraduate training program accredited by the ACGME or the
RCPSC? Yes No
To qualify for licensure in California, applicants who are
graduates of an international medical school must complete at least
four (4) months of postgraduate training in GENERAL MEDICINE as
part of the requirement. Applicants who are graduates of a U.S. or
Canadian medical school, who have not completed postgraduate
training required for licensure by July 1, 1990, must also complete
four (4) months of training in GENERAL MEDICINE prior to licensure.
The GENERAL MEDICINE requirement may be satisfied by actual
clinical practice where the applicant had direct patient care
responsibilities for at least four months in any particular
specialty or sub-specialty area. L3A
07A-100 (Revised 01/2019)
Do not sign and date this form prior to the last day of any
postgraduate training year which will be used by the applicant to
qualify for licensure. Completion of this form will certify that
the applicant has satisfactorily completed a period of accredited
postgraduate training at this facility and that the applicant has
acquired the skill and qualifications necessary to safely assume
the unrestricted practice of medicine in this state.
APPLICANT INFORMATION MBC
ATTENTION: PROGRAM DIRECTOR
months.
MARRIAGE, OR ADOPTION. Only the Program Director 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
practice of medicine in this state.
PROGRAM DIRECTOR OFFICIAL CERTIFICATION The program director
signing this form is formally certifying and documenting under
penalty of perjury that the applicant received instruction
appropriate for the particular postgraduate level and that he/she
satisfactorily completed periods of training in accordance with the
accepted standards and the criteria defined as equating to
satisfactory performance. The program director is attesting to the
fact that the applicant has acquired the skill and qualifications
necessary to safely assume the unrestricted
I hereby declare under penalty of perjury under the laws of the
State of California that all of the information contained on these
forms is true and correct. I further certify that the training
program is accredited by the ACGME or the RCPSC to offer the type
and level of training completed by the applicant named on the Form
L3A, and the applicant was trained in an ACGME or RCPSC slotted
program position.
Use Only
Date
Program
THE PERSON WHO SIGNS THIS FORM MAY NOT BE RELATED TO THE APPLICANT
BY BLOOD,
Director’s Signature &
SIGNATURE OF PROGRAM DIRECTOR DATE (Signature Stamp Is Not
Acceptable)
NOTE: If a hospital seal is not available, the program director
shall also sign in the section below in the presence of a notary
public.
SIGNATURE OF PROGRAM DIRECTOR: (SIGN FULL NAME IN THE PRESENCE OF
NOTARY)
A notary public or other officer completing this certificate
verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document.
State of _________________________
County of ________________________
Subscribed and sworn to (or affirmed) before me on this ________
day of ________________, 20_______,
by, __________________________________________ proved to me on the
basis of satisfactory evidence
(PRINT PROGRAM DIRECTOR’S NAME) HOSPITAL or NOTARY SEAL to be the
person who appeared before me.
SIGNATURE OF NOTARY PUBLIC
Program Director’s Signature
L3B NOTE: The completed forms must be mailed directly from the
program to the Board to be acceptable.
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
CERTIFICATE OF CLINICAL TRAINING (This form is only required of
international medical school graduates)
Type or Print Legibly APPLICANT INFORMATION MBC Use Only
Applicant Information
LEGAL NAME: Last First Middle Suffix
Date of Birth (m/dd/yyyy) Last 4 Digits of U.S. SSN or ITIN Medical
School of Graduation
MEDICAL SCHOOL: PLEASE COMPLETE THIS FORM IN THE ENGLISH LANGUAGE
Report undergraduate clinical clerkships in which the applicant
participated in DIRECT, HANDS-ON DIAGNOSIS OR TREATMENT OF PATIENTS
IN A CLINICAL SETTING. Please use as many forms as necessary to
document ALL undergraduate clinical clerkships completed during
enrollment in medical school.
Note: Section 2089.5(c) of the Business and Professions Code
requires that instruction in the clinical courses shall total a
minimum of 72 weeks. Instruction in the core clinical courses shall
total a minimum of 40 weeks in length with a minimum of (8) weeks
of medicine, (8) weeks of surgery, (6) weeks of pediatrics, (6)
weeks of ob/gyn, (4) weeks of psychiatry, and (4) weeks of family
medicine. (Family Medicine is required for applicants who graduated
after May 1, 1998)
Clinical Subject (List one subject per line)
Facility Name City/State/Province/Country
(mm/dd/yyyy)
AFFIX MEDICAL SCHOOL SEAL
I certify that I am the President, Dean, or Registrar and hereby
declare under penalty of perjury under the laws of the State of
California that the above statements are true and correct.
_________________________________________
_____________________________ PRINTED NAME OF SCHOOL OFFICIAL TITLE
OF SCHOOL OFFICIAL
_________________________________________
____________________________ SIGNATURE OF SCHOOL OFFICIAL
DATE
Attention Medical School: THE PERSON WHO SIGNS THIS FORM MAY NOT BE
RELATED TO THE APPLICANT BY BLOOD, MARRIAGE OR ADOPTION. Only the
President, Dean, or Registrar may sign this form. If the signature
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. L5
Rev. L5 Staff
Initials & Date
NOTE: The completed form must be mailed directly from the medical
school to the Board to be acceptable.
07A-100 (Revised 01/2019)
Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL
BOARD
Sacramento, CA 95815-5401 Phone: (916) 263-2382 O F C A L I F O R N
I A
Fax: (916) 263-2487 Protecting consumers by advancing high quality,
safe medical care. www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer
Services and Housing Agency | Department of Consumer Affairs
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 APPLICANT INFORMATION MBC Use Only
Applicant Information
LEGAL NAME: Last First Middle Suffix
Date of Birth (mm/dd/yyyy) Last 4 Digits of U.S. SSN or ITIN
Medical School of Graduation
PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR TO COMPLETE CLERKSHIP
INFORMATION Facility Name Facility Address
Clinical Specialty Dates of Training (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
International Medical School. Yes No
Name of the U.S., Canadian, or International Medical School. (If
affiliated)
This facility does have an ACGME-accredited residency training
program. Yes No ACGME 10-digit program #
(https://apps.acgme.org/ads/Public): Specialty:
OFFICIAL CERTIFICATION ATTENTION: A signature stamp is not
acceptable. 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.
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.
PRINTED NAME OF PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR
SIGNATURE OF PROGRAM DIRECTOR OR CLINICAL INSTRUCTOR DATE
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: (SIGN FULL
NAME IN THE PRESENCE OF NOTARY)
State of County of
Subscribed and sworn to (or affirmed) before me on this ________
day of ________________, 20_______,
by, __________________________________________ proved to me on the
basis of satisfactory evidence (Print Name of Program Director or
Clinical Instructor)
to be the person who appeared before me.
SIGNATURE OF NOTARY PUBLIC L6
A notary public or other officer completing this certificate
verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document.
HOSPITAL or NOTARY SEAL
Initials & Date
NOTE: The completed form must be mailed directly from the facility
to the Board to be acceptable.
07A-100 (Revised 01/2019)
Application, Fees, and Fingerprints
The Application fee is non-refundable. Refer to the Fee Schedule
for further details.
Application Fee $491
Complete all fields, answer all questions and have the application
notarized. All six pages must be submitted together.
Forms L1A-L1F
Examination Documentation
A Certification Status Report from the Educational Council for
Foreign Medical Graduates (ECFMG) is required to verify your
certification is valid. You may obtain further information from
their website at www.ecfmg.org. The ECFMG must mail the
Certification Status Report directly to the Board to be
acceptable.
Status Report
Official Examination Scores from the Federation of State Medical
Boards (FSMB)
A Certificate of Clinical Training, Form L5, is required to report
all undergraduate clinical clerkships. Complete the applicant
information at the top of the form and mail it to your medical
school. The form will need to be completed, signed and dated by the
school official and affixed with the official medical school seal.
You may print or copy as many forms as necessary to provide a
complete breakdown of your undergraduate clinical training. The
Form(s) L5 must be mailed directly from the medical school to the
Board to be acceptable.
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/HRV (Za stvaranje Adobe PDF dokumenata najpogodnijih za
visokokvalitetni ispis prije tiskanja koristite ove postavke.
Stvoreni PDF dokumenti mogu se otvoriti Acrobat i Adobe Reader 5.0
i kasnijim verzijama.) /HUN
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/LVI
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/NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken
die zijn geoptimaliseerd voor prepress-afdrukken van hoge
kwaliteit. De gemaakte PDF-documenten kunnen worden geopend met
Acrobat en Adobe Reader 5.0 en hoger.) /NOR
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