LOUISIANA STATE BOARD OF MEDICAL EXAMINERS
FILL IN ONLINE PRIOR TO PRINTING. NAME: LAST. FIRST. MIDDLE. SUFFIX (SR, JR) SOCIAL SECURITY NUMBER. DRIVER’S LICENSE # & STATE. CONTROLLED SUBSTANCES PERMIT #’S. DEA: STATE: FED: BUSINESS ADDRESS: * This address will appear on the LSBME website. **Renewal notices will be sent to this address. STREET & NO. (DO NOT USE P.O. BOX) CITY. … ................
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