HOME | ABOUT US | SERVICES | CONTACT  

Please fill out this evaluation form to its' entirety. The information that you provide will give us an idea of your interest and eligibility for state licensure. This information will not be shared with anyone outside of J&D Licensure Consultants and its' agents. Please be advised that filling out this form in no way obligates you to any of our services. Additionally, if you would like to fax us this form CLICK HERE. DEMOGRAPHICS: Last Name:         First Name:   M.I.:   Degree Type:           Date (mm/yyyy):   SSN:              UPIN:   Personal TX ID:   Medicare #:       Medicaid #:   Practice Address:   City:   State:   Zip:                  Time Zone:   Organization:    Address:         City:                    State:       Zip:                       Country (if outside US):    Time Zone:      Phone:            (Day) (Evening) Email:             Fax:                LICENSES: All Past and Present Licenses (both Active & Inactive) State License License Number (Please list the corresponding License Numbers respectively): Issue Date (Please list the corresponding Issue Dates respectively): Expiration Date (Please list the corresponding Expiration Dates respectively): Status (Please list the corresponding License Status respectively): State(s) you are interested in being licensed State License: Date License Needed: Type Needed: EDUCATION: Medical School Attended: Medical School Location: Year of Graduation: US or Foreign Graduate? United States Foreign Graduate What is your highest level of Training? Fifth Pathway Internship Residency Fellowship Other Are you board certified? Yes No No, but board eligible If certified, which specialty? EXAMINIATIONS: Which exam(s) did you take? COMPLEX ECFMG FLEX FMGEMS LMCC NBME NBOME SPEX STATE BOARD USMLE Year(s) each exam was passed (please list years respective to test(s) seletion): Exam#1 Year Passed Exam#2 Year Passed Exam#3 Year Passed Exam#4 Year Passed Exam#5 Year Passed MALPRACTICE and DISCIPLINARY HISTORY Malpractice Claims: #Pending        #Settled         #Dismissed   Have you ever been subject to any disciplinary actions taken against a state medical license, hospital, and/or Medicare/Medicaid priviledges? Yes No Preferred Method of Contact: Phone (Daytime) Phone (Evening) Email How did you hear about us? Advertisement (Magazine, Classified, Newspaper) Referral Website Other Category: Medical License Application Processing Individual/Small Group Credentialing Network Credentialing & Development LTC & Subacute Facility Credentialing Credentialing/MSS Staffing Medical Billing Additional Comments: Thank you for filling out this informational form. Please be advised that this information is confidential and will be used only for the purposes of assisting you with your licensure needs.

©2003-2004 J&D Licensure Consultants. All Rights Reserved.
This site is professionally designed and maintained by EMANIC Consulting.
For any questions or comments regarding this site email the webmaster at webmaster@jdlicensureconsultants.com