Instructions for completing the license application

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Instructions for completing the license application
for a New Jersey Medical License
Read the application and instructions before completing the application.
Each section of the application is explained in these instructions -follow them carefully.
Completing the enclosed application and mailing it to the Board office does not constitute the
completion of your application. You must request verifications and certifications from schools,
employers, etc.(third parties) using forms enclosed in this packet and follow-up with the third
parties to ensure materials are sent directly to the Board office. Do not substitute a different
form/document for the one requested or those provided with the application. Your application
cannot be reviewed and approved until all documentation regarding your education, postgraduate training and professional experience are received. Request verification from all
third parties immediately. Get them expedited, if possible.
The application must be submitted with a certified check or money order in the amount of
$325.00 (nonrefundable) and three photographs, which must be signed and dated. An
endorsement fee and registration fee will be requested just prior to your license being issued.
Your application reviewer will inform you regarding how much is owed when it is due.
Type or print neatly. All questions must be answered. For “Yes” or “No” questions, circle the
correct answer. If you determine a question does not apply to you, please indicate that fact by
writing “N/A” as your response. When space provided is insufficient, attach additional sheets of
paper. Print your first name, middle initial and last name on each page of the application and
on each attachment. Attachments are considered part of your application.
Due to confidentiality restrictions, information about the status of your license
application can only be discussed with you unless you provide written authorization for it
to be discussed with another interested party. This restriction includes your spouse and/or
family members.
Please note -if you are using a independent credentialing service to assist with the submission
of elements required for your application, you are still required to complete every section of
the application and ensure all third-party forms are completed and returned directly to the
Board. Applicants choosing to utilize the Federation Credentials Verification Service (FCVS)
should refer to FAQs found under the Applicants heading on the home page of this web site to
find which application elements will be met by the Board’s receipt of an FCVS packet on your
behalf.
When preparing your curriculum vitae, be complete and accurate. You must account for all
periods of time beginning with your entry into medical school.
When the Board has received your application, fee and third-party documentation, your file will
be reviewed. At that time, you will be notified of any additional information or clarification that
may be required to complete your application. Should you have questions about the
application, or process, please contact the Board by telephone at 609.826.7100, by fax at
609.984.3930 or by e-mail at mailto:[email protected]
Falsification or misrepresentation of any item or response on this application or any
attachment hereto is sufficient basis for denying a license.
Section One -Demographics
1. Print your legal name. This is the name that will appear on your license certificate. If you
have changed your name, submit a copy of the associated legal document with this
application. Print your current first name, middle initial and last name on the copy of the
legal document.
2. Print any other name which may appear on documents you submit, or others may submit
as part of this application (i.e., maiden name, legal name change, etc.). If you have
changed your name, submit a copy of the associated legal document with this
application. Print your current first name, middle initial and last name on the copy of the
legal document.
3. Print your current mailing address and contact information. Your mailing address cannot be
a post office box unless you also enter your street address. Application reviewers will
contact you via e-mail, and follow-up in writing to your mailing address. It is your
responsibility to notify the Board immediately, in writing by mail or FAX, of changes to your
mailing address. You may also provide an Address of Record and home/business addresses
(attach to application). The Address of Record will be printed on your license certificate. If
you do not provide an Address of Record before becoming licensed, your mailing address
will be printed on your license certificate. Your name and address will be posted on the
Online License Directory. As a matter of information, under New Jersey public disclosure
law, any of your license addresses must be provided if requested under the Open Public
Records Act.
4. Enter your date and place of birth. Federal law limits the issuance or renewal of professional
licenses to U.S. citizens or qualified aliens. To comply with federal law you must provide
evidence of citizenship status. If you were born in the United States, submit a copy of
your birth certificate or passport with this application. If you were born elsewhere,
submit a copy of your passport or a copy of an official document granting citizenship status.
If you are not a U.S. citizen, submit a copy of the official immigration document authorizing
you to work in the United States. Questions about your immigration status and whether it is
a qualifying status under federal law should be directed to the U.S.C.I.S. at (800) 3755283.
5. Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey Child Support Enforcement Law,
N.J.S.A. 54:50-25 of the New Jersey Taxation law, and Section 1128E(b)(2)A of the Social
Security Act, the Board is required to obtain your Social Security number. The Board is
further obligated to provide your Social Security number to the Director of Taxation, the
Probation Division or any other agency responsible for child support enforcement, upon
request, and to the National Practitioner Data Bank and the H.I.P. Data Bank when
reporting adverse actions.
Pursuant to the Federal Privacy Act (5 U.S.C. Section 55a(note(b)), the Board is requesting
your consent to use your Social Security number for the following purposes: 1) to verify
identity; 2) to aid in the collection of financial obligations due and owing the Board or any
other State agency; and 3) to aid in the disclosure to State or federal law enforcement and
licensing officials and agencies of information obtained in investigations pertaining to
licensure and disciplinary proceedings.
6. Circle Yes or No. If “Yes,” enter the type of license/registration for which you applied, and
the date you applied (month/year).
Section Two - Education
Pre-Medical Education
Answer the questions by circling yes or no.
Print the information requested for each college/university you attended. Enter the dates in the
following format: From Month/Year - To Month/Year.
Medical Education
List every medical school in which you were ever enrolled EVEN IF NO CREDIT WAS
GRANTED OR NO CREDIT WAS SOUGHT FOR THE STUDY. Enter your full name at the top
of form BME-MEV and mail a copy of the form to every school you attended - not just the
school from which you graduated. Direct the school(s) to return the form with an official
transcript directly to the N.J.B.M.E. address on the form. Forms submitted by you will not be
accepted - they must be mailed directly from the school to the N.J.B.M.E.
If submitting a copy of a foreign medical school diploma or transcript: A copy of the
original diploma must be notarized. Transcripts and diplomas which are not in English must be
translated by one of the approved translation agencies (Appendix A). If a translated copy is not
received, the foreign language copy will be returned to you for translation.
Graduates of foreign medical schools must be certified by the Educational Commission for
Foreign Medical Graduates (E.C.F.M.G.). Contact the E.C.F.M.G. (see Appendix A) and request that
your certification be sent directly to the N.J.B.M.E.
Applicants educated in India, Pakistan or Bangladesh - submit an original and official Mark
Sheet for each Bachelor of Science and/or Bachelor of Medicine (M.B.B.S.) Examination taken.
Failed examinations must be included. Submit the certificate verifying completion of a year of
compulsory rotating internship.
Clinical Clerkships - Circle Yes or No for each category.
Board Certifications - Complete by entering the required information for each certification you
hold.
Endorsement Examinations - Enter the dates for each exam taken. Enter “N/A” for exams not
taken. If your application is based on a licensing examination taken in another state prior to
December 31, 1972, complete Section 1 and mail Form BME-VSL to the state medical board
which administered the exam. Direct them to complete Sections 2, 3 and 4 and return it directly
to the N.J.B.M.E. at the address on the form. This form is not to be used if you are applying on the
basis of FLEX Endorsement, National Board Endorsement, U.S.M.L.E. Endorsement or N.B.O.M.E./
COMLEX Endorsement. State exams taken after December 31, 1972, will not be accepted for
endorsement.
If you are applying on the basis of FLEX Endorsement, National Board Endorsement, U.S.M.L.E.
Endorsement or N.B.O.M.E./COMLEX Endorsement, contact the appropriate organization (see
Appendix A) and have your report sent directly to the N.J.B.M.E.
Postgraduate Training
List each training program (including Fifth Pathway Program, internship, residency and/or fellowship)
in which you have participated and the information requested on the form for each program. Enter
your full name at the top of Form BME-VPT and mail a copy of the form to each training program
you list whether you received credit, no credit or partial credit. Direct the training program to mail
the form directly to the N.J.B.M.E. at the address on the form.
Section Two -Education (continued)
Graduates of L.C.M.E./A.O.A. approved medical schools and graduates of foreign medical
schools who graduated prior to July 1, 1985, must successfully complete at least one year of
A.C.G.M.E. or A.O.A. approved postgraduate training.
Graduates of foreign medical schools who graduated after July 1, 1985 and prior to July 1,
2003, must successfully complete a minimum of three (3) years of A.C.G.M.E. or A.O.A.
approved postgraduate training.
All applicants who graduated from medical school after July 1, 2003, must successfully
complete a minimum of two (2) years of postgraduate training in an A.C.G.M.E. or A.O.A.
accredited program and have a signed contract for a third year of training in an accredited
program where at least two years of that training are in the same field or would, when
considered together, be credited toward the criteria for certification by a single specialty board.
Section Three -Employment/Malpractice History/Other Licenses
Privileges/Affiliation/Employment/Appointments History
Print the required information for every private office, residency program, H.M.O., etc. where
you were employed or with whom you were affiliated for the five-year period that immediately
precedes the filing of this application. Enter your full name at the top of Form BME-PEA and
mail a copy of the form to every entity you have listed in this section of your application.
Malpractice History
Answer all of the questions. Attach a written statement identifying every malpractice suit in
which you have been listed as a defendant. Include the name of the plaintiff, date of the
incident and status of each suit, i.e. open, dismissed, closed with payment. Provide your
personal description of the clinical aspects of the case as it would be explained to a fellow
professional and a copy of the Complaint or Bill of Particulars. If the malpractice suit has been
closed, you must provide a copy of the Final Disposition including the amount of payment on
your behalf. Failure to provide this information when submitting your application will delay
your application review. If a malpractice carrier has taken an action with reference to
you or your policy, you must submit an explanation and documentation of the action
from the carrier.
Enter your full name at the top of Form BME-MI and forward a copy of the form to every
malpractice insurance carrier which has provided coverage to you during the three-year period
immediately preceding the submission of your license application. If your malpractice coverage
is/was provided by a hospital, forward the form to the Risk Management office of the hospital.
Direct the hospital and insurance carriers to mail the form directly to the N.J.B.M.E. -forms
submitted by you will not be accepted.
Verification of State License
Print the required information for each license and/or permit ever held in another state. For
each license or permit held, no matter the status, complete Section 1 of Form BME-VSL and
mail the form to the state which granted it. Direct them to complete Section 2 and 4 and mail
it directly to the N.J.B.M.E.
N ote: All applicants meeting the Postgraduate Training criteria detailed in Section Two of
these instructions, who have never held a plenary medical license in any other state or
jurisdiction, are not required to submit forms BME-PEA, BME-MI and BME-VSL.
Section Four -Character, Ethics and Medical Conditions
Information regarding moral character and ethical professional responsibility
Answer all questions by circling either Yes or No. For all “Yes” answers, attach a full
explanation and any pertinent documentation. Print your first name, middle initial and last
name on each page of any attachment.
Question a. asks about any arrests, charges or offenses you may have committed. Carefully
review the following definitions and instructions before answering the question.
Definitions for the purpose of this question:
“Arrest” includes any detaining, holding or taking into custody by any police or other law
enforcement authorities to answer for the alleged performance of any “offense.”
“Charge” includes any indictment, complaint, information, summons, or other notice of the
alleged commission of any “offense.”
“Offense” includes all felonies, crimes, high misdemeanors, misdemeanors, disorderly persons
offenses, petty disorderly offenses, driving while intoxicated/impaired motor vehicle offenses,
violations of probation or any other court order, and local ordinance violations.
Instructions for the purpose of question a. Answer “Yes” and provide all information to the
best of your ability EVEN IF:
1.
2.
3.
4.
5.
6.
You
The
You
You
You
The
did not commit the offense charged;
charges were dismissed or subsequently downgraded to a lesser charge;
completed a Pretrial Intervention (P.T.I.) or equivalent diversionary program;
were not convicted;
did not serve any time in prison or jail; or
charges or offenses happened a long time ago.
Answer “No” IF:
1. You have never been arrested or charged with any crime or offense; or
2. The records relating to a charge, an arrest or conviction have been expunged by the court
or a government agency.
Questions h. through k. -Under N.J.S.A. 2A:17-56-44d, an answer of “Yes” to any of questions
h.(a), h.(b), i., j., k. will result in a denial of licensure. Furthermore, any false certification of
these questions may subject you to a penalty, including, but not limited to, immediate
revocation or suspension of licensure.
Medical Conditions/Chemical Substances
Answer all questions by circling “Yes,” “No” or “Not Applicable” (N/A), unless you are asserting
your Fifth Amendment Privilege against self-incrimination. If you are asserting your Fifth
Amendment Privilege, write that in the space under the first paragraph on the page.
If you are answering the questions, attach a detailed explanation for answers of “Yes,” and
include your printed first name, middle initial and last name on each page of the attachment.
Section Four -Character, Ethics and Medical Conditions (continued)
For the purposes of these questions, the following phrases or words have the following
meanings:
“Ability to practice medicine” is to be construed to include all of the following:
1. The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned
medical judgments and to learn and keep abreast of medical developments; and
2. The ability to communicate those judgments and medical information to patients and other
health care providers with or without the use of aids or devices, such as voice amplifiers;
and
3. The physical capability to perform medical tasks with or without the use of aids or devices
such as corrective lenses or hearing aids.
“Medical condition” includes physiological, mental or psychological conditions or disorders, such
as, but not limited to orthopedic, visual, speech and hearing impairments, cerebral palsy,
epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental
retardation, emotional or mental illness, specific learning disabilities, H.I.V. disease,
tuberculosis, drug addiction and alcoholism.
“Chemical substances” is to be construed to include alcohol, drugs or medications, including
those taken pursuant to a valid prescription for legitimate medical purposes and in accordance
with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the
completion of the application. Rather, it means recently enough so that the use of drugs may
have an ongoing impact on one’s functioning as a licensee, or within the past two years.
“Illegal use of controlled substances” means the use of controlled dangerous substances
obtained illegally (e.g. heroin or cocaine) as well as the use of controlled dangerous substances
which are not obtained pursuant to a valid prescription or not taken in accordance with the
directions of a licensed health care practitioner.
Documents to be completed and/or returned with your application:
1. Certification and Authorization Form for a Criminal History Background Check The New Jersey Division of Consumer Affairs is required to conduct criminal history record
background checks of all health care professionals prior to the issuance of an initial license
to practice a health care profession (N.J.S.A. 45:1-28 et seq.). In order for the Division
to conduct a criminal history record background check, you must complete the enclosed
Certification and Authorization form and return the form with your license application.
Upon receipt, the Board will mail you the information you will need to undergo the
criminal history background check. The Board will forward to you information
you will need to schedule an appointment to have your fingerprints electronically
recorded if you work/reside in New Jersey, or live in a community near the State’s
borders (go to www.njconsumeraffairs.gov/chbc/ZipCodeList.pdf on the Web for a
complete list of the ZIP codes of these nearby communities). The recording of
your fingerprints is necessary to conduct the criminal history background check. If
you do not live in a community near the State’s borders, you will be sent information
on your option for having your fingerprints recorded.
2.
Waiver and Certification - Print your first name, middle initial and last name at the
top of the form. Read, complete and sign the form in the presence of a Notary Public.
Applications must be submitted to the N.J.B.M.E. within 30 days of notarization. The
Board considers all information submitted to be the responsibility of the applicant.
Please ensure that all of the information being submitted is accurate and complete.
3. Curriculum Vitae - Submit a copy of your curriculum vitae with your application. List
all activities chronologically, with the month and year dates for the beginning and ending
of each period of your medical education, postgraduate training, professional experiences
and activities. The list must begin with the first medical school in which you were enrolled
and continue through to the present date with no gaps. Label all periods of unemployment
as such, and identify your activities during any period of unemployment. Provide
addresses for all employers.
4. Photographs - Submit three passport-size professional photographs with your
application. The photographs must not be more than six months old and must be signed
and dated.
5.
Form BME-MEV - Enter your full name
school you attended whether credit was
directly to the N.J.B.M.E. with an official
follow-up with the school(s) to ensure
fashion.
at the top of this form and mail a copy to each
earned or not. The school must return the form
transcript. Keep track of the forms you mail, and
the form is completed and mailed in a timely
6.
Form BME-VPT - Enter your full name at the top of this form and mail a copy to each
training program in which you participated whether credit was earned or not. The facility
must return the form directly to the N.J.B.M.E. Keep track of the forms you mail and
follow-up with the facility(ies) to ensure the form is completed and mailed in a timely
fashion.
7.
Form BME-PEA - Enter your full name at the top of this form and mail a copy to each
facility at which you worked or with whom you are or have been affiliated. The facility
must return the form directly to the N.J.B.M.E. Keep track of the forms you mail, and
follow-up with the facility(ies) to ensure the form is completed and mailed in a timely
fashion.
8.
Form BME-MI - Enter your full name at the top of this form and mail a copy to each
medical malpractice insurance carrier from whom you have obtained medical malpractice
insurance, and/or to the Office of Risk Management for each hospital with whom you
have been affiliated or employed. The malpractice insurance carrier and/or the hospital
must return the form directly to the N.J.B.M.E. Keep track of the forms you mail, and
follow-up to ensure the form is completed and mailed in a timely fashion.
Documents to be completed and/or returned with your application (continued)
9. Form BME-VSL -Make copies of the form and complete the top section for each state
where you have taken a written examination, or have held a license to practice medicine
whether the license is in active, inactive or some other status. The state must complete the
appropriate sections of the form and return it directly to the N.J.B.M.E. Keep track of the
forms you mail, and follow-up to ensure the form is completed and mailed in a timely
fashion.
10.Examination and Board Action History Report (E.B.A.H.R.) -Contact the Federation of
State Medical Boards (see Appendix A) and request that your E.B.A.H.R. be sent directly to
the N.J.B.M.E.
11.American Medical Association/American Osteopathic Association Physician Profile
Contact the appropriate organization (see Appendix A) and have your Profile sent directly to
the N.J.B.M.E.
12.Name Change -If your name as it appears on your medical school diploma is not the same
as it appears on documentation submitted, include a copy of the legal document effecting
this change. Print your current first name, middle initial and last name on the copy of the
document.
To request scores/transcripts and/or reports/profiles from any of the organizations
listed below, to complete your application, refer to Appendix A for contact
information.
National Board Of Medical Examiners (N.B.M.E.) National Board of Osteopathic Medical
Examiners (N.B.O.M.E.) -COMLEX/N.B.O.M.E. Federation of State Medical Boards (F.S.M.B.) U.S.M.L.E., SPEX and FLEX examination scores and E.B.A.H.R. Educational Commission for
Foreign Medical Graduates (E.C.F.M.G.) American Medical Association (A.M.A.) American
Osteopathic Association (A.O.A.)
Use these addresses when sending documents to the N.J.B.M.E.
Mailing Address: via U.S. Postal Service -
via other mail delivery service
New Jersey Board of Medical Examiners
New Jersey Board of Medical Examiners
140 East Front Street -3 Floor
P.O. Box 183
Trenton, NJ 08625
140 East Front Street -3 Floor
Trenton, NJ 08608
rd
rd
Application for Licensure by the
State Board of Medical Examiners of New Jersey
This entire application must be typed or legibly printed.
Section One - DEMOGRAPHICS
1. Name ________________________________________________________________
Middle Initial (M.I.)
Last
First 2. List any other name which may appear on documents submitted as part of this
application (See Instructions).
_____________________________________________________________________
3. Contact Information E-mail address ___________________@________
Mailing address (This may not be a post office box.)
_____________________________________________________________________
City
State/Country
ZIP/Postal Code
Street
(________)__________________
(_______)_________________
Area Code
Telephone Number
Area Code
Cell Phone Number
(_______ )___________________
Area Code
4. Date of Birth _____ /_____ /_____
Month
Day
5. Social Security Number
Work Telephone Number
(_______)_________________
Area Code
Place of Birth ______________
Year
__________
________
FAX Number
City
State
Country
_________
I ______ consent _______ do not consent to the use of my Social Security number
for any of the additional purposes set forth in the Instructions. I understand that
my consent is voluntary and that if I do not consent, no adverse action or inference will
be taken or drawn.
6. Have you previously applied for a New Jersey medical license or residency training
permit?
Yes
No
If “Yes,” specify and indicate the date submitted:
______________________________
Type
_________________________________
Month/Year
-1-
Type
Month/Year
Print Name_____________________________________
First
M.I.
Last
Section Two - Education
Pre-Medical Education
Did you take, pass and receive credit for a minimum of 60 (sixty) post-secondary,
college level or equivalent credits prior to commencing medical school OR can you
Yes
No
demonstrate that you have obtained the substantial equivalent?
Did you pass at least one college-level course in each of the subject areas listed below?
Biology
Yes
No
Chemistry Yes
No
Physics
Yes
No
List the name and location of every college or university attended where pre-professional,
post-secondary instruction was received:
Name
City/State/Country
Dates of Attendance
(From - To)
________________________
___________________
___ / ___ - ___ / ___
________________________
___________________
___ / ___ - ___ / ___
________________________
___________________
___ / ___ - ___ / ___
Medical Education
Month
Year
Month
Year Name of Medical School(s)
1st year _________
_____
to _______
______ _________________________
2nd year _________
_____
to _______
______ _________________________
3rd year
_________
_____
to _______
______ _________________________
4th year
_________
_____
to _______
______ _________________________
5th year
_________
_____
to _______
______ _________________________
6th year _________ _____ to _______
______ _________________________
Name of institution conferring degree:_________________________________________
Date degree was awarded: _________________ Type (circle one): Medical Doctor or Doctor of Osteopathy
-2-
Print Name_____________________________________
First
M.I.
Last
Section Two - Education (continued)
Clinical Clerkships
During your medical school training, did you complete clinical clerkships of at least four (4)
weeks duration in the following core rotations or specialties?
Medicine Yes
Pediatrics Yes
Surgery Yes
No
No
No
OB/GYN
Psychiatry
Yes
Yes
No
No
Board Certifications
List any certifying board(s) below:
Certification
Date Awarded/Expiration Date
/
/
Board
/
Endorsement Examinations
National Board Examination: Part 1 Date ___ / ___ Part 2 Date ___ / ___ Part 3 Date ___ / ___
Month
Year
Month
U.S.M.L.E.: Step 1 Date ___ / ___ Step 2 Date ___ / ___
Month
Year
Month
Year
Month
Year
Step 3 Date ___ / ___
Year
Month
Year
FLEX: Component 1/FLEX Date ___ / ___ Component 2/FLEX Date ___ / ___
Month
Year
Month
Year
FLEX prior to 12/1994 Weighted Average ________________
Sister State: State: ____________ Date __________________
N.B.O.M.E./COMLEX: Part 1 Level 1 ______ Part 2 Level 2 ______ Part 3 Level 3 ______
Postgraduate Training
List below each training program (including Fifth Pathway Program, internship, residency
and/or fellowship) in which you have participated.
Dates (From - To)
Institution
Specialty
Credit/No Credit/
Partial Credit
PGY1
PGY2
PGY3
PGY4
___ / ___ - ___ / ___
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
___ / ___ - ___ / ___
___ / ___ - ___ / ___
___ / ___ - ___ / ___
Fellowship ___ / ___ - ___ / ___
Other
___ / ___ - ___ / ___
____________
____________
________________
____________
____________
________________
____________
____________
________________
____________
____________
________________
____________
____________
________________
____________
____________
________________
-3-
Print Name_____________________________________
First
M.I.
Last
Section Three - Employment/Malpractice History/Other Licenses
Privileges/Affiliation/Employment/Appointments History
From
To
Employer/Facility
____/_____
Name:
____/____ Position:
Address
Street:
City:
Malpractice Carrier:
State/ZIP code:
Name:
Street:
Month
Year
____/_____
Month
Year
____/____ Position:
City:
Malpractice Carrier:
State/ZIP code:
Name:
Street:
Month
Year
____/_____
Month
Year
____/____ Position:
City:
Malpractice Carrier:
State/ZIP code:
Name:
Street:
Month
Year
____/_____
Month
Year
____/____ Position:
City:
Malpractice Carrier:
State/ZIP code:
Name:
Street:
Month
Year
____/_____
Month
Year
____/____ Position:
City:
Malpractice Carrier:
State/ZIP code:
Name:
Street:
Month
Year
____/_____
Month
Year
____/____ Position:
City:
Malpractice Carrier:
State/ZIP code:
Name:
Street:
Month
Year
____/_____
Month
Year
Month
Year
____/____ Position:
Month
Year
Malpractice Carrier:
-4-
City:
State/ZIP code:
Print Name_____________________________________
First
M.I.
Last
Section Three - Employment/Malpractice History/Other Licenses (continued)
Malpractice History
Answer the following questions:
a. Have you been named as a defendant in a medical malpractice suit? Yes
No
b. Have you been denied malpractice insurance coverage? Yes
No c. Have you been reassigned to a risk retention or high-risk group? Yes
No
d. Has your carrier limited or reduced your coverage?
Yes
No
e. Has your carrier required you to have office monitoring?
Yes
No
f.
Has any carrier limited their coverage of your practice? Yes
No
g. Have you limited your practice in order to obtain or maintain
Yes
No
malpractice coverage? Identify every malpractice suit in which you have been listed as a defendant and the status
of the suit, i.e. open, dismissed or closed with payment.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Verification of State License/Sister State Endorsement
List below all state(s)/countries in which you hold or have ever held a medical license or
residency training permit, and the status of the license/permit:
State
Number
Circle One
Other
________
__________
Active
Inactive
____________
________
__________
Active
Inactive
____________
________
__________
Active
Inactive
____________
Specify
Specify
Specify
-5-
Print Name_____________________________________
First
M.I.
Last
Section Four - Character, Ethics and Medical Conditions Information regarding moral character and ethical professional responsibility
a.
Have you ever been arrested for, formally accused of, charged with, indicted for or
convicted of the commission of any crime or offense, whether state, federal, or in other
countries, including offenses categorized as misdemeanors, high misdemeanors or
felonies? (NOTE: If you have been arrested or had a conviction for which you have been
informed the record has been expunged, please verify that the expungement has in fact
been implemented prior to answering “No” to this question.) (A dismissal is not an
expungement.) Yes
No
b. Have you ever been denied a license to practice medicine or eligibility to sit for a licensing
exam in this State or in any other state or jurisdiction, foreign or domestic?
Yes
No
c. Has any action been taken or is any action now pending against your professional license
or have you been permitted to surrender or otherwise relinquish your license to avoid
inquiry, investigation or action by any other licensing authority or regulatory agencies?
Yes
No
d. Have you ever been denied eligibility to participate in a graduate medical education
program in this State or any other state or jurisdiction, foreign or domestic?
Yes
No
e. Have you ever been denied privileges or had your privileges to practice terminated or
limited?
Yes
No
f. Have you ever been terminated from or have you ever been asked to resign from your
hospital staff membership, internship, residency position or fellowship? Yes
No
g. Have you ever been permitted to resign while you were under review or investigation
by a health care facility or, in return for not conducting an investigation?
Yes
No
h. Do you currently have a child-support obligation?
If “Yes,” you must answer (a) and (b) below:
(a) Are you in arrears in payment of said obligation?
(b) Does the arrearage match or exceed the total amount payable
for the past six months?
Yes
No
Yes
No
Yes
No
i. Have you failed to provide any court-ordered health insurance coverage during the past six months?
Yes
No
j. Have you failed to respond to a subpoena relating to either a paternity or child-support related arrest warrant?
Yes
No
k. Are you the subject of a child-support-related arrest warrant?
-6-
Yes
No
Print Name_____________________________________
First
M.I.
Last
Section Four - Character, Ethics and Medical Conditions (continued)
Medical Conditions/Chemical Substances
If you have a good-faith reason to believe that answering these questions may expose you
to possible criminal prosecution, you may assert the Fifth Amendment privilege against selfincrimination. If you do so, your application will still be processed. However, you may later
be directed by the Attorney General to answer these questions, provided that the Attorney
General first grants you immunity afforded by statutory law pursuant to N.J.S.A. 45:1-20.
a. Do you have a medical condition which in any way impairs or limits your ability to practice
medicine with reasonable skill and safety?
Yes
No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated
because you receive ongoing treatment (with or without medications) or participate
in a monitoring program? (NOTE: If you receive such ongoing treatment or participate
in such a monitoring program, the Board will 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 not eligible for licensure.) N/A
Yes
No
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated
because of the field of practice, the setting or the manner in which you have chosen to
practice? N/A
Yes
No
d. Have you ever been diagnosed as having or have you ever been treated for pedophilia,
exhibitionism or voyeurism?
Yes
No
e. Are you currently engaged in the illegal use of controlled dangerous substances?
Yes
No
If “Yes,” are you participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not
engaging in the illegal use of controlled dangerous substances? Yes
No
f. Does your use of chemical substance(s) in any way impair or limit your ability to
N/A
practice medicine with reasonable skill and safety? Yes
No
If you answered “Yes” to any of the questions above, you must explain in detail on
a separate sheet of paper the reason for your responses.
-7-
Print Name_____________________________________
First
M.I.
Last
Waiver
I hereby authorize all hospitals, institutions, organizations, my references, employers (past
and present), business and professional associates (past and present), and all governmental
agencies and instrumentalities (local, state, federal, or foreign) to release to the New Jersey
State Board of Medical Examiners any information, files or records requested by the Board.
I further authorize the New Jersey State Board of Medical Examiners to release to any
organizations, individuals and groups listed above, any information which is material to
my application, relating to clinical, residency or postgraduate programs as well as hospital
privileges or staff appointments.
I am the person referred to in the preceding application for licensure to practice medicine
and surgery in the State of New Jersey. I have carefully read the questions in the foregoing
application and have answered them completely, without reservations of any kind, and I
declare under penalty of perjury that my answers and statements made by me herein are
true and correct. Should I furnish any false information in this application, I hereby agree
that such act shall constitute cause for denial, suspension or revocation of my license to
practice medicine and surgery in the State of New Jersey.
Certification
“I certify that the information entered on this form is true and complete to the best of my
knowledge, and further acknowledge that if the above information is willfully false, I am subject
to punishment and/or disciplinary sanction including license denial, suspension/revocation
or the imposition of civil penalties as may be provided by law. I am also aware that as a
condition of licensure I am required to notify the State Board of Medical Examiners, in writing,
within 21 days, of any subsequent changes to the information reported on my application.”
__________________________________________________
Signature of Applicant
___________________________________________________
Name of Notary Public (please print)
Affix Seal Here
__________________________________________________
Signature of Notary Public
__________________________________________________
Date Signed
This application, once complete, must be signed in the presence of a notary and forwarded
to the Board within 30 days of the notarization. -8-
Medical Education Verification Form
Applicant’s name:__________________________________________________________
Medical school: ___________________________________________________________
Medical school address: _____________________________________________________
Street
City
State/Country
Zip/Postal Code
Telephone number: (
) ______________________
Area Code
1. Did this physician attend the medical school noted above?
Yes
No
2. What were the applicant’s dates of enrollment? ____________ to ___________
Month /Year
3. Did this physician graduate from this medical school?
If “No,” please explain below:
Month /Year
Yes
No
_____________________________________________________________________
_____________________________________________________________________
4. What was the date of graduation?
___________________________
Month /Year
5. Did this individual take a leave of absence during his/her attendance at this medical
school?
Yes
No
If “Yes,” what was the reason for the leave of absence?
_____________________________________________________________________
_____________________________________________________________________
6. Was this individual on probation during his/her attendance at this medical school?
Yes
No
7. Was this individual ever disciplined or under investigation during his/her attendance at
this school?
Yes
No
8. Were any negative reports filed by instructors regarding this individual?
Yes
No
9. Were any special requirements imposed on this individual that were not required of
Yes
all other students at his/her level of education?
No
Please supply any additional comments or information that the Board should consider prior
to determining this applicant’s eligibility for licensure.
________________________________________________________________________
________________________________________________________________________
Print Name of Registrar: ______________________________
Signature of Registrar: ________________________________
Date: ______________________________________
Please return with an official transcript directly to:
Seal of
Medical
School
N.J. State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625-0183
BME-MEV-08
Verification of Postgraduate Training
Applicant’s name:__________________________________________________________
Hospital: ________________________________________________________________
Hospital address:__________________________________________________________
Street
City
State/Country
Zip/Postal Code
Hospital telephone number: (
) ______________________
Area Code
1. In what type and level(s) of training did this physician participate at your facility?
Check each level in which this physician participated. Provide starting and ending
dates of training, type of training and whether credit was awarded.
Dates
Credit
(Month/Year)
None
Partial
Full
Specialty
PGY 1
PGY 2
PGY 3
PGY 4
Fellowship
Other
2. Was the residency/fellowship accredited by A.C.G.M.E. or A.O.A.?
Yes
No
3. Was the physician placed on probation, suspended or in any way sanctioned/
disciplined or placed under investigation while at your facility?
Yes
No
4. Was the physician granted a leave of absence or break from his/her training? Yes
No
5. Were any restrictions placed on this physician’s activities that were not
placed on all other residents/fellows at his/her level of training?
Yes
No
Yes
No
6. Were any formal patient or staff complaints filed against this physician?
7. Were any malpractice actions filed naming this physician as a defendant
that involved his/her period of training at your facility?
Yes
No
If you answered “Yes” to any one of questions 3-7, please attach an explanation, and sign
and date the attachment. Also, please attach any additional comments or information that
the Board should consider prior to determining this applicant’s eligibility for licensure.
__________________________________________
Printed Name of Program Director
__________________________________________
Signature of Program Director
__________________________________________
Hospital
Seal
Date form completed
Please return directly to: N.J. State Board of Medical Examiners
If the hospital does not
P.O. Box 183
have a seal, a letter
Trenton, New Jersey 08625-0183
attesting to this fact,
on hospital stationery,
must accompany this
BME-VPT-08
certificate.
Verification of Privileges/Affiliation/Employment/Appointment
_____________________________________
License Applicant’s Name
_____________________________________
Hospital/Facility Name
return completed form to:
_____________________________________
N.J. State Board of Medical Examiners
Street Address
P.O. Box 183
_____________________________________
Trenton, NJ 08625-0183
City
State/Country
ZIP/Postal Code
_____________________________________
(Area Code) Telephone Number
_____________________________________
from ___ /___ /____ to ___ /___ /____
Position held at your facility
1. Was this physician placed on probation, suspended or in any way
sanctioned/disciplined while at your facility? 2. Was this physician granted a leave of absence while employed at your facility?
3. Were any restrictions placed on this physician’s activities or privileges
that were not placed on others holding similar positions?
4. Was this physician subject to non-routine monitoring and/or non-routine
quality assessment review?
5. Was this physician involuntarily removed from a call schedule?
Yes
Yes
6. Was this physician the subject of a negative review while at your facility?
7. Was this physician the subject of an investigation while at your facility?
8. Were any malpractice actions filed naming this physician during
his/her period of employment at your facility?
9. Did this physician leave your facility in good standing?
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
10. Would you recommend this physician for privileges or consider rehiring
this physician at your facility?
Yes
No
If you answered “Yes” to any one of questions 1-8, please attach an explanation. You may also
attach additional comments or information that the N.J. State Board of Medical Examiners
should consider prior to determining this applicant’s eligibility for licensure. All attachments
should be on your facility’s letterhead.
__________________________________________
Printed Name and Title of Certifying Official
__________________________________________
Signature of Certifying Official
__________________________________________
Date form was completed
BME-PEA-08
Hospital
Seal
If the hospital does not
have a seal, a letter
attesting to this fact,
on hospital stationery,
must accompany this
certificate.
Malpractice Insurance Verification
_________________________________ has applied for a medical license with the State
Insured’s Name
of New Jersey. He/she held medical malpractice insurance issued by your company. Please
complete this form, attach relevant supporting documentation concerning any medical
malpractice cases in which this practitioner was named and the business card of the individual
completing this form and return directly to:
N.J. State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625
_______________________________________________________________________
Malpractice Insurance Company Name
________________________________________________________________________
Street Address
Dates of coverage:
City
State
ZIP code
(Area Code) Phone
from: ____ /_____ /_____to: ____ /_____ /____
Dates should include entire period the insured was covered, not just the dates of
the current policy.
List the name(s) and status of each case in which the doctor has been involved. Attach
supporting documents concerning the status of the case.
Plaintiff’s Name
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Status
_____________________
_____________________
_____________________
_____________________
1. Was this doctor ever denied malpractice coverage?
Yes
No
2. Was this doctor’s practice ever curtailed or limited?
Yes
No
3. Was this doctor ever assessed a surcharge based upon specific claims history?
4. Was office monitoring or special hospital monitoring ever required for this doctor?
Yes
Yes
No
No
5. Was this doctor ever subjected to underwriting review based upon specific
claims history or for any other cause?
Yes
No
__________________________________________________________
Print the name and title of the person completing this form.
__________________________________________________________
Signature
__________________________________________________________
Date form completed
BME-MI-08
Verification of State License/Examination
I, _____________________________________________ , born _____/______/______
First Name
Middle Initial
Last Name
Month
Day
Year
Social Security No.____-____-____ , hold/held medical license _______________________
Registration number
issued by_________________________. I am requesting that you complete this verification
State
form and mail it to the N.J. State Board of Medical Examiners (address below) as per my
authorization. Thank you.
I hereby authorize the State of _____________________________ to release all of the
information in its files concerning my license/examination and any actions or pending actions
against my license to the New Jersey State Board of Medical Examiners.
_____________________________________________
__________________
Signature
Date
Section 2 - To be completed by the licensing/examination entity
The State of _________________ certifies that ______________________ was issued license
Name of State
Name of Physician
registration ______________. Date Issued ___ /___ /___ Expiration Date ___ /___ /___
Month
Day
Year
Month
Day
Year
License Number
The status of this license is currently: (Circle one) Active
Inactive Other (specify)___________
1. Is the license in good standing?
If “No,” please attach details and certified copies of any orders.
Yes
No
2. To your knowledge, has this physician ever been disciplined by
your board or any other regulatory agency?
Yes
No
If “Yes,” please attach details and certified copies of any orders.
3. Is there presently or has there been in the past a disciplinary
proceeding against this licensee? Yes
No
If “Yes,” please attach details and certified copies of any orders.
4. Is there presently or has there been in the past an investigation
conducted relative to this licensee? Yes
No
If “Yes,” please attach details and certified copies of any orders.
Please attach additional comments or information that the Board should consider prior to
determining this applicant’s eligibility for licensure.
Section 3 - State Licensing Examination Verification
After a written examination administered by this board in the following subjects:
________________________________________________________________________
_________________________________and upon obtaining a general average of ______
percent, the above license was issued.
Section 4 - Certification
_________________________________ ________________________
Printed name and title of Certifying Official
Date form completed
Signature of Certifying Official
____ /_____/_____
Please return directly to: N.J. State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625-0183
Board
Seal
BME-VSL-08
Official Use Only
Official Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
Resubmit
________________________
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
License Type 2
________________________
Board or Committee
________________________
Applicant’s Number
________________________
Certification and Authorization Form
For a Criminal History Background Check
Directions: Answer all of the questions on this form.
Mr.
__________________________________________________________ (_ ________________________)
Mrs.
Last First Middle
Maiden Name
Ms.
2. Address ____________________________________________________________________________________________
1. Name
Street or P.O. Box 3. Date of birth __ __ /__ __ /__ __ Month Day Year City
Sex:
Male
State
Female
ZIP code 4. Social Security number __________/______ /_ ________
5. Have you completed the fingerprinting process for any Board or Committee of the New Jersey Division of Consumer
Yes
No
Affairs since November 2003? If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
________________________________________________ Board or committee requiring the fingerprinting
________________________________________________
Month and year you were fingerprinted
If you were fingerprinted after November 2003 as part of the criminal history background process for licensure or
certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background check
conducted for the Department of Education, another state agency or another state does not apply) you will not be required to
be fingerprinted a second time. However, the Division must perform a criminal history background check each time you apply
for licensure or certification. The fee for this service is $22.00. Payment should be made in the form of a check or money
order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor traffic offenses such as a parking or speeding
Yes
No
violations need not be listed.)
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and filed.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within five (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Continuation on the reverse side ➨
Certification
I,_ ______________________________________________, in making this application to the Board or Committee for
certification or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufficient to deny certification or licensure or to withhold renewal of or suspend or revoke a certificate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualifications for certification or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________ __________________________________ Signature of applicant Date
Rev. 11/21/13
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Translation Company of America
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Box 1529
Morristown, NJ 07960
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Berlitz School of Languages
31D Hulfish Street
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(609) 497-6571
Inlingua School of Language/Translation Svs.
95 Summit Avenue Summit, NJ 07901
(908) 522-0622
www.inlinguametrony.com
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171 E. Ridgewood Ave Ridgewood, NJ 07450
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Translation Company of New York, Inc.
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The Language Center, Inc
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(732) 613-4554
Endorsement Agencies
Federation of State Medical Boards
www.fsmb.org
National Board of Medical Examiners
(N.B.M.E.) www.nbme.org
Examination and Board Action History Report
(E.B.A.H.R.)
(817) 868-4041
American Medical Association (A.M.A.)
http://www.ama-assn.org
Educational Commission for Foreign Medical
(E.C.F.M.G.) http://www.ecfmg.org
American Osteopathic Association
http://www.osteopathic.org
Controlled Dangerous Substance Registration
(State of N.J.) http://www.njconsumeraffairs.gov/drug/
National Board of Osteopathic Examiners
(N.B.O.M.E.) http://www.nbome.org
Appendix A

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