Transcription of ALABAMA BOARD OF MEDICAL EXAMINERS - ALBME
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ALABAMA BOARD OF MEDICAL EXAMINERS - ALBME
Page 1. ALABAMA BOARD OF MEDICAL . EXAMINERS . Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116. application for licensure OF physician assistant . I. physician assistant 's Name in Full Home Address City State Zip Male Place of Birth Date of Birth Sex Social Security #* Phone #: _____ Email: _____. *Pursuant to Ala. Code 30-3-194, it is mandatory that we request and that you provide your social security number (SSN) on this application. The uses of your SSN are limited to the purpose of administering the state child support program and intra-agency for identification purposes. If your SSN is not provided, your application is not complete, and no license will be issued.
Page 1 ALABAMA BOARD OF MEDICAL EXAMINERS P.O. Box 946 / Montgomery, AL 36101-0946 / (334) 242-4116 APPLICATION FOR LICENSURE OF PHYSICIAN ASSISTANT I. Physician Assistant’s Name in Full Home Address City State Zip
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