Physician Assistant Application for Licensure …

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PROOFNew Jersey Office of the Attorney GeneralDivision of Consumer AffairsState Board of Medical ExaminersPhysician Assistant Advisory Committee140 East Front Street, 3rd Floor, Box 183Trenton, New Jersey 08625(609) 826-7100 Assistant Application for Licensure ChecklistUse this checklist as a guide to assure your Application is complete. Applicant s name:___________________________________ ___________________________ I. Application A. Answer each question completely. B. Be sure to have the Application notarized. C. Attach one (1) passport photograph (2 x 2 ) to the Application . D. Provide a valid daytime telephone number (include area code). E. Attach additional documents (if applicable). (For example, to explain gaps in curriculum vitae history, a statement of medical activity, or other.) List here: ________________________________________ ________________________________________ _______ ________________________________________ ________________________________________ _______ F.

PROOF. Checklist. III. Transcripts: Verification of Education A. Physician Assistant Program IV. Curriculum Vitae V. Application Fee Personal check or money order payable to the Physician Assistant Advisory Committee, in the amount of

  Applications, Verification, Licensure, Physician, Assistant, Physician assistant application for licensure