Ala. Admin. Code r. 540-X-3-Appendix-B
Under Alabama law, this document is a public record and will be provided upon request.
Application is made through the school, program, or institution.
Required demographic information:
Name in full (First, Middle, Last, M.D./D.O.)
Alternate name(s) used
Address (Street, City, State, Zip)
Email address
Place of birth
Date of birth
Social Security Number (Pursuant to Ala. Code § 30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete and no license will be issued)
Sex
Telephone (H or C)
Telephone (W)
Name of Institution
Type of license (check one): Resident Fellow Distinguished Professor Specialty Professor Visiting Professor State Institution
Required background information:
If your answer is “yes,” please provide a detailed explanation in the space provided.
Legal:
1. Have you ever been arrested for, cited for, charged with, or convicted of any crime, offense, or violation of any law, felony, or misdemeanor, including, but not limited to, offenses related to the practice of medicine or state or federal controlled substances laws, or driving under the influence (DUI)?
*This question excludes minor traffic violations such as speeding and parking tickets but includes felony and misdemeanor criminal matters that have been dismissed, expunged, sealed, subject to a diversion or deferred prosecution program, or otherwise set aside.
2 Have you ever been arrested for, cited for, charged with, or convicted of any sex offender laws or required to register as a sex offender for any reason?
4. To your knowledge, as of the date of this application, are you the subject of an investigation or proposed action by any law enforcement agency?
Administrative/Regulatory:
9. To your knowledge, as of the date of this application, are you the subject of an investigation or proposed action by any federal agency, any licensing board/agency, or any hospital or health care facility?
Fitness to Practice:
12. The Board recognizes that licensees encounter potentially impairing health conditions just as their patients and other health care providers do, including psychiatric or physical illnesses which may impact cognition, as well as substance use disorders. The Board expects its licensees to address their health concerns, both mental and physical, in a timely manner to ensure patient safety. Licensees should seek appropriate medical care and should limit their medical practice when appropriate and as needed. The Board encourages licensees to utilize the services of the Alabama Professionals Health Program, a physician advocacy organization dedicated to improving the health and wellness of medical professionals in a confidential manner. The failure to adequately address a health condition, where the licensee is unable to practice medicine with reasonable skill and safety to patients, can result in the Board taking action against the license to practice medicine.
I have read and understand the statements above.
[Applicant Attestation]
Education/Training/Experience:
14. Has your medical education, training, or medical practice been interrupted or suspended, or have you ceased to engage in direct patient care, for a period longer than 60 days for any reason other than a vacation or for the birth or adoption of a child?
If yes, please provide a brief explanation.
19. Medical School: List all medical schools attended, dates, and complete addresses of institutions. Do not list post-graduate medical education training.
20 Post-Graduate medical education training: List all post-graduate medical education training since graduation from medical school, dates, and complete addresses of institutions. Do not list practice experience.
22. Have you successfully completed a written licensing examination?
If yes, please choose: ABMS or AOA board certification exam; USMLE; COMLEX; Other
Release
I, [name prints here], certify that all of the information supplied in the foregoing application is true and correct to the best of my knowledge, that the photograph submitted is a true likeness of myself and was taken within sixty days prior to the date of this application. I acknowledge that any false or untrue statement or representation made in this application may result in the denial of this application or the revocation of my license to practice medicine and criminal prosecution to the fullest extent of the law. I further consent to and authorize the release of this application and any information submitted with it or information collected by the Alabama Board of Medical Examiners in connection with this application, including derogatory information, to any person or organization having a legitimate need for the information, and I release the Alabama Board of Medical Examiners from all liability for the release of this information. I further consent to and authorize the release of information, including derogatory information, which may be in the possession of other individuals or organizations to the Alabama Board of Medical Examiners, and I release this individual or organization from any liability for the release of information.
Applicant’s signature
Attach or Upload Photograph
I understand and agree that by typing my name, I am providing an electronic signature that has the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing information has been provided by me and is true and correct to the best of my knowledge, information and belief.
Date
Applicant’s typed name
Certification of Institution: This is to certify that the aforementioned individual is making application for a limited certificate of qualification at this institution.
I understand and agree that by typing my name, I am providing an electronic signature that has the same legal effect as a written signature pursuant to Ala. Code §§ 8-1A-2 and 8-1A-7. I attest that the foregoing information has been provided by me and is true and correct to the best of my knowledge, information and belief.
Date
Name of Dean-School of Medicine, Director-Residency Training Program, Warden/Medical Director
Print application, attach a recent photograph of yourself, have Dean-Medical School, Director-Residency Training Program, or Warden/Medical Director sign, and return original to the Alabama Board of Medical Examiners.
Author: Alabama Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, §§34-24-70, 34-24-73, and 34-24-75.
Editor’s Note: Appendix B, Application for Certificate to Practice Medicine through Examination, was repealed and Appendix C was renamed Appendix B per certification filed February 27, 2018; effective April 14, 2018.
History: Amended: Filed July 26, 1999; effective August 30, 1999. Amended: Filed February 17, 2012; effective March 23, 2012. Amended: Filed July 22, 2013; effective August 26, 2013. Amended: Filed March 20, 2014; effective April 24, 2014. Repealed and New Rule: Filed February 27, 2018; effective April 14, 2018. Amended: Filed February 20, 2019; effective April 7, 2019. Amended: Published February 28, 2020; effective April 13, 2020. Repealed and New Rule: Published December 30, 2022; effective February 13, 2023. Repealed and New Rule: Published March 31, 2025; effective May 15, 2025.