ALABAMA BOARD OF MEDICAL EXAMINERS Appendix BApplication for Licensure of Physician Assistant  Under Alabama law, this document is a public record and will be provided upon request. Required demographic information: Name in full (First, Middle, Last, M.D./D.O.)Alternate name(s) usedAddress (Street, City, State, Zip)Email addressPlace of BirthDate of BirthSocial 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)SexTelephone (H or C)Telephone (W) 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, cited for, charged with, or convicted of any sex offender laws or required to register as a sex offender for any reason? 3.    Have you ever had a judgment rendered against you or action settled relating to an action for injury, damages, or wrongful death for breach of the standard of care in the performance of your professional service (“malpractice”)? 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: 5.    Have you ever had any Drug Enforcement Administration registration and/or state controlled substances registration denied, voluntarily surrendered while under investigation, or subject to any discipline, including, but not limited to revocation, suspension, probation, restriction, conditions, reprimand, or fine? 6.    Have you ever been denied prescription privileges for non-controlled or legend drugs by any state or federal authority? 7.    Have you ever been denied a license to practice as an assistant to physicians in any state or jurisdiction or has your application for a license to practice as an assistant to physicians been withdrawn under threat of denial? 8.    Has your certification or license to practice as an assistant to physicians in any state or jurisdiction ever been subject to any discipline, including but not limited to revocation, suspension, probation, restrictions, conditions, reprimand, or fine? 9.    Have your staff privileges at any hospital or health care facility ever been revoked, suspended, curtailed, limited, placed under conditions restricting your practice? 10.   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 heath care facility? Fitness to Practice: 11.  Are you currently suffering from any condition that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner? 12.   Within the past five years, have you raised the issue of any physical or psychiatric health disorder as a defense, mitigation, or explanation for your actions during any administrative or judicial proceeding or investigation; any injury or other proceeding; or any proposed termination by an educational institution; employer; government agency; professional organization; or licensing authority? 13.   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, an 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 as a physician assistant.I have read and understand the statements above.[Applicant Attestation] Education/Training Experience: 14.  As of the date of this application, has it been more than two years since the last time you were actively engaged in clinical practice or direct patient care? 15.  Has you 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?      When entering attendance dates below, you may use the first date of the month instead of the exact date. . (Ex: attended August 1990 – July 1994, enter 08/01/1990 – 07/01/1994)             Education (beginning with undergraduate degree)            Upload a copy of your diploma(s) reflecting graduation from
a Physician Assistant Program            School Name            Start Date            End Date            School Address             Activities Since Beginning Undergraduate Degree (cover all
time periods)            Place of Employment or Activity            Start Date            End Date            Address Examination Have you successfully completed the Physician Assistant National Certifying Examination?If YES, upload verifying documentation from the National Commission on
Certification of Physician Assistants (NCCPA).If NO, have you ever taken the examination?Are you registered to take the PANCE?If YES upload verifying documentation from the NCCPA.PANCE Test date: Current PracticeAre you currently registered, certified to or working for any other primary supervising physician in another state? i.e., Are you presently working as a physician assistant? If so, answer yes.    If YES, provide the name and principal practice location of each primary supervising physician to whom you are certified.  In addition, state your designated working hours per week for each physician listed. Certification of Licensure in Other StatesList all states where you have been certified/registered/licensed as an assistant to physicians.  Primary source verification is required from any state that does not report physician assistant data to the Federation of State Medical Boards. Certification and Release: I, [full name], certify, that all of the information supplied in the submitted-application is true and correct to the best of my knowledge, that the photograph submitted herein is a true likeness of me 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 revocation of any certification / licensure granted. 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 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 release this person or organization from any liability for the release of information. 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. _________________________________________Physician Assistant’s Signature          Attach Photograph,If one was not uploaded.

ALABAMA BOARD OF MEDICAL EXAMINERS

DECLARATION OF CITIZENSHIP AND LAWFUL PRESENCE OF AN

ALIEN FOR PUBLIC BENEFITS AND LICENSING/PERMITTING PROGRAMS

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1621, provides that, with certain exceptions, only United States citizens, United States non‑citizen nationals, non‑exempt “qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive covered state or local public benefits.

With certain exceptions, Ala. Code § 31‑13‑1, et. seq. prohibits aliens unlawfully present in the U.S. from receiving state or local benefits.  Every U.S. Citizen applying for a state or local public benefit must sign a declaration of Citizenship, and the lawful presence of an alien in the U.S. must be verified by the Federal Government.

Act 2011‑535 also requires every individual applying for a permit or license to demonstrate his/her U.S. citizenship or if the applicant is an alien, he/she must demonstrate his/her lawful presence in the United States.

Directions:  This form must be completed and submitted by individuals applying for licenses or permits.

SECTION 1 ‑‑‑ APPLICANT INFORMATION

NAME: (Last)(First)(M.I.)

DATE OF BIRTH:

SECTION II ‑‑‑ U.S. CITIZENSHIP OR NATIONAL STATUS

Are you a citizen or national of the United States (check one)   Yes/No

If you answered YES: (1) Provide an original (only in person at agency office) or legible copy of document from attached List A or other document that demonstrates U.S. citizenship or nationality and (2) Complete Section IV.

If you answered No:  Complete Sections III and IV.

Name of document provided:

SECTION III – ALIEN STATUS

Are you an alien lawfully present in the United States? Yes/No

If you answered Yes:  (1) Provide an original (only in person at agency office) or legible copy of the front and back (if any) of a document from attached List B or other document that demonstrates lawful presence in the United States. (2) Complete Section IV.  Information from the documentation provided will be used to verify lawful presence through the United States Government.

If you answered No: Complete Section IV.

Name of document provided:

SECTION IV ‑‑ DECLARATION

I declare under penalty of perjury under the laws of the State of Alabama that the answers and evidence I provided are true and correct to the best of my knowledge.

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.

APPLICANT’S SIGNATURE

DATE

LIST A

DOCUMENTS DEMONSTRATING U.S. CITIZENSHIP

1. (1)  The applicant's driver's license or nondriver's identification card issued by the division of motor vehicles or the equivalent governmental agency of another state within the United States if the agency indicates on the applicant's driver's license or nondriver's identification card that the person has provided satisfactory proof of United States citizenship.
2. (2)  The applicant's birth certificate that satisfactorily verifies United States citizenship.
3. (3)  Pertinent pages of the applicant's United States valid or expired passport identifying the applicant and the applicant's passport number.
4. (4)  The applicant's United States naturalization documents or the number of the certificate of naturalization.
5. (5)  Other documents or methods or proof of United States citizenship issued by the federal government pursuant to the Immigration and Nationality Act of 1952, and amendments thereto.
6. (6)  The applicant’s Bureau of Indian Affairs card number, tribal treaty card number, or tribal enrollment number.
7. (7)  The applicant’s consular report of birth abroad of a citizen of the United States of America.
8. (8)  The applicant’s certificate of citizenship issued by the United States Citizenship and Immigration Services.
9. (9)  The applicant’s certification of report of birth issued by the United States Department of State.
10. (10) The applicant’s American Indian card, with KIC classification, issued by the United States Department of Homeland Security.
11. (11) The applicant’s final adoption decree showing the applicant’s name and United States birthplace.
12. (12) The applicant's official United States military record of service showing the applicant's place of birth in the United States.

13. (13) An extract from a United States hospital record of birth created at the time of the applicant's birth indicating the applicant's place of birth in the United States.

    LIST B

    DOCUMENTS INDICATING STATUS OF QUALIFIED

    ALIENS, NONIMMIGRANTS, AND ALIENS PAROLED

    INTO U.S. FOR LESS THAN ONE YEAR

    The documents listed below that are registration documents are indicated with an asterisk (“*”).

14. a.   “Qualified Aliens”

    Evidence of “Qualified Alien” status includes the following:

    Alien Lawfully Admitted for Permanent Residence

    ·    Form I‑551 (Alien Registration Receipt Card, commonly known as a “green card”); or

    ·    Unexpired Temporary I‑551 stamp in foreign passport or on * I Form‑94.

    Asylee

    ·    * Form I‑94 annotated with stamp showing grant of asylum under section 208 of the INA;

    ·    * Form I‑688B (Employment Authorization Card) annotated “274.a12(a)(50”;

    ·    * Form I‑766 (Employment Authorization Document) annotated “A5”;

    ·    Grant letter from the Asylum Office of the U.S. Citizenship and Immigration Service; or

    ·    Order of an immigration judge granting asylum.

    Refugee

    ·    *  Form I‑94 annotated with stamp showing admission under § 207 of the INA;

    ·    *  Form I‑688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or

    ·    *  Form I‑766 (Employment Authorization Document) annotated “A3”

    Alien Paroled Into the U.S. for at Least One Year

    ·    *  Form I‑94 with stamp showing admission for at least one year under section 212(d)(5) of the INA.  (Applicant cannot aggregate periods of admission for less than one year to meet the one‑year requirement.)

    Alien Whose Deportation or Removal Was Withheld

    ·    *  Form I‑688B (Employment Authorization Card) annotated “274a.12(a)(10);

    ·    *  Form I‑766 (Employment Authorization Document) annotated “A10”; or

    ·    Order from an immigration judge showing deportation withheld under §243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under § 241(b)(3) of the INA.

    Alien Granted Conditional Entry

    ·    *  Form I‑94 with stamp showing admission under §203(a)(7) of the INA;

    ·    *  Form I‑688B (Employment Authorization Document) annotated “274a.12(a)(3)”; or

    ·    *  Form I‑766 (Employment Authorization Document) annotated “A3.”

    Cuban/Haitian Entrant

    ·    *  Form I‑551 (Alien Registration Receipt Card, commonly known as a “green card”)  with the code CU6, CU7, or CH6;

    ·    Unexpired temporary I‑551 stamp in foreign passport or on * Form I‑94 with the code CU6 or CU7; or

    ·    Form I‑94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA.

    Alien Who Has Been Declared a Battered Alien Subjected to Extreme Cruelty

    ·    U.S. Citizenship and Immigration Service petition and supporting documentation

Author: Alabama State Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§34-24-293, 34-24-3-298, 34-24-299, 34-24-303. 34-24-306.

Editor’s Note: Appendix B was repealed and Appendix D was renamed Appendix B per certification Filed February 27, 2018; effective April 14, 2018.

History: Repealed and Replaced: Filed September 21,1998; effective October 26, 1998. Amended: Filed July 23, 1999; effective August 27, 1999. Repealed and New Appendix: Filed September 19, 2002; effective October 24, 2002. Amended: Filed November 19, 2004; effective December 24, 2004. Amended: Filed December 18, 2008; effective January 22, 2009. Amended: Filed May 20, 2010; effective June 24, 2010. Amended: Filed December 16, 2010; effective January 20, 2011. Repealed and New Appendix: Filed February 27, 2018; effective April 14, 2018. Amended: Filed August 22, 2018; effective October 6, 2018. Amended: Published March 31, 2021; effective May 15, 2021. Amended: Published December 30, 2022; effective February 13, 2023. Amended: Published March 31, 2025; effective May 15, 2025.