STATE OF CALIFORNIA -- STATE AND CONSUMER SERVICES …



STATE AND CONSUMER SERVICES AGENCY- Department of Consumer Affairs EDMUND G. BROWN JR,. Governor

MEDICAL BOARD OF CALIFORNIA

Licensing Program

REQUEST FOR RENEWAL

UNDER BUSINESS AND PROFESSIONS CODE SECTIONS 2111 AND 2113

To: Medical Board of California

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815

Attention: Phillip Egeston, Special Programs Coordinator

χ 2111 Appointment χ 2113 Registration χ First Renewal

χ Second Renewal

Name of Appointee/Registrant

1. An appointment pursuant to Section 2111 must be renewed annually, and may not exceed a total of three years.

2. A Certificate of Registration pursuant to Section 2113 must be renewed annually, and may be renewed routinely for a period of two years from the date of the issuance of the original certificate. Upon request by the dean of a medical school, the Medical Board of California may exercise its discretion in deciding whether to renew a Certificate of Registration beyond the third year. The dean must substantiate the registrant’s progress towards medical licensure and provide appropriate documentation confirming the registrant’s receipt of a certificate issued by the Educational Commission for Foreign Medical Graduates.

Name of Supervisor

Signature of Supervisor Medical School

Title Department

Date

Name of Medical School Dean

Signature of Medical School Dean

(SP Renewal) Revised May 2008

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