INSTRUCTIONS: ALABAMA VERIFICATION OF OTHER STATE LICENSES

As part of the process of applying for an Alabama license to practice as a physician assistant or anesthesiologist assistant, you must obtain verification from all states in which you have been certified, registered or licensed in this capacity, or have ever applied for this status. This is done by mailing the form discussed in this article to all applicable states. This form can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Verification Of Other State Licenses Step 1: Print or type your full name on the first blank line.

Alabama Verification Of Other State Licenses Step 2: Enter your signature on the second blank line.

Alabama Verification Of Other State Licenses Step 3: Enter your identifying number in the state of Alabama on the third blank line.

Alabama Verification Of Other State Licenses Step 4: Enter the date on the fourth blank line.

Alabama Verification Of Other State Licenses Step 5: Enter your street address, city, state and zip code on the fifth blank line.

Alabama Verification Of Other State Licenses Step 6: Mail the form to the appropriate medical board of each applicable state for completion. On the first blank line, the person completing the form will enter your name.

Alabama Verification Of Other State Licenses Step 7: On the second blank line, the person completing the form will enter your certificate, registration or license number.

Alabama Verification Of Other State Licenses Step 8: On the third blank line, the person completing the form will enter the date this certificate, registration or license number was issued.

Alabama Verification Of Other State Licenses Step 9: On the fourth blank line, the person completing the form will enter the date on which this certificate, registration or license was terminated.

Alabama Verification Of Other State Licenses Step 10: On the fifth blank line, the person completing the form will enter the reason the certificate, registration or license was terminated.

Alabama Verification Of Other State Licenses Step 11: On the sixth blank line, any derogatory remarks will be entered. On the seventh blank line, any miscellaneous remarks will be entered.

Alabama Verification Of Other State Licenses Step 12: The person completing the form will sign and date it, as well as entering their title and the name of the applicable state board.