12202064B8Cypress323993257Name Part I To be completed by applicant Institution Name Department Address City State ZIP Phone Number Part II To be completed by Training Institution The aboven ID: 893593
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1 12/2020,64B8
12/2020,64B8 If you are using FCVS do not submit this form.Complete verifications must be sent directly from the chairman/director of the post-graduate training program to the board office by fax to (850) 412-1268 or by mail to: Cypress323993257 Name: _____________________________________________ Part I: To be completed by applicant Institution Name: ______________________________________________________________________________ Department: __________________________________________________________________________________ Address: _____________________________________________________________________________________ City: _____________________________ State: ____________________________________ ZIP: _____________ Phone Number: ____________________________________ Part II: To be completed by Training Institution The above-named doctor has applied for licensure in the state of Florida. Please complete this section and submit to the above address. Dates of internship/residency/fellowship: _____________ to _____________ MM/DD/YYYY MM/DD/YYYY Matriculation date: _____________ MM/DD/YYYY Completion date: _____________ MM/DD/YYYY Specialty: __________________________ The levels completed under your purview: 6. Accredited by: Program Director/Chair Name _________________________________________________________ Signature ____________________________________________________ Date ________________ MM/DD/YYYY PGY I PGY II PGY III PGY IV PGY V ACGME RCPSC CFPC Other: _________________________