Applicants should download or print the Application Kit—it contains all the necessary documents.
- Do not send these forms to the Board of Registration in Medicine. All completed forms must be sent to your training program.
- Do not complete and mail these forms until you have been accepted into an accredited training program.
- The kit has a set of instructions. Please read the instructions carefully before filling out the forms.
- Application Kit for Initial Limited License file size 1MB
The application kit is an Adobe PDF (Portable Document Format). You must have the Adobe Acrobat Reader Plugin for your browser in order to download or print the documents. Download the free Adobe Reader, then run the installation program to add the plugin to your browser.
The application documents are also available in Word format. IF YOU CHOOSE NOT TO USE THE KIT, THEN YOU SHOULD DOWNLOAD OR PRINT THE DOCUMENTS BELOW. ALL RELEVANT FORMS MUST BE SUBMITTED.
- Initial Limited Instructions
- Checklist (Form 1)
- Initial Limited Application (Form 2)
- Initial Limited Supplement (Form 3)
- Medical Education Verification (Form 4A)
- Medical Education Verification (Form 4B)
- State License Verification (Form 5)
- Evaluation (Form 6)
- Authorization for Release (Form 7)
- Name Change
- Equivalency Waiver (Form J)
- Form E-1
- Form E-2
- Affidavit for Social Security Number
This information is provided by the Board of Registration in Medicine.