PART A: TO BE COMPLETED BY APPLICANT - California

BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY ? GAVIN NEWSOM, GOVERNOR

DEPARTMENT OF CONSUMER AFFAIRS ? PHYSICIAN ASSISTANT BOARD

2005 Evergreen Street, Suite 2250, Sacramento, CA 95815

P (916) 561-8780 | F (916) 263-2671 | paboard@dca. | pab.

PHYSICIAN ASSISTANT BOARD

VERIFICATION OF LICENSURE

PART A: TO BE COMPLETED BY APPLICANT

Regardless of the status, applicants who have been licensed, certified, or otherwise registered in any state, country or with any federal agency

as a health care provider (e.g., PA, RN, EMT, CNA, CPT, etc.) are required to request a verification of the license, certificate, or registration.

? You are not required to use the Physician Assistant Board¡¯s (Board) Verification of Licensure form when requesting a verification as the Board

accepts other agencies¡¯ verification forms.

? Copies of your license, certificate, or card do not fulfill this requirement and should not be submitted to the Board.

? Do not submit this form with your application if you have not been licensed, certified, or registered as a health care provider.

? The verification is essential in assessing the applicant for licensure as it not only confirms the details of the license, certificate, or

registration, it provides the Board with disciplinary history.

1. Name

Last

2. Other Names/Aliases

First

Middle

3. Telephone Number

4. Mailing Address

Number and Street

City

State

ZIP Code

5. Email Address

I hereby authorize your agency to release information concerning my license/certificate/registration status.

Signature

Date

PART B: TO BE COMPLETED BY LICENSING BOARD OR AGENCY

The person listed above has applied for a physician assistant license in California. Please complete Part B and mail, or email, the form directly to

the Board. If disciplinary action has been taken against this licensee, please provide all official public records directly to the Board. Faxed copies

are not acceptable.

License/Certificate/Registration Issued To

License/Certificate/Registration Type

Name of the State/County/Federal Agency of Issuance

License/Certificate/Registration Number

Issue Date

Expiration Date

License/Certificate/Registration Status

Has this agency taken any disciplinary action against this license/certificate/registration?

Yes

No

CERTIFICATION

OFFICIAL SEAL

(If Available)

Signature

Printed Name

Title of Authorized Official

Agency¡¯s Name

Date

Telephone Number or Email Address

Rev 11/22/22 PDE 22-331

2005 Evergreen St., Suite 2250, Sacramento, CA 95815-3893 ¡ñ (916) 561-8780 ¡ñ paboard@dca. ¡ñ pab.

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