Transcription of BME-Medical Education Verification Form
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BME-Medical Education Verification Form
New Jersey Office of the Attorney GeneralDivision of Consumer AffairsState Board of medical Box 183 Trenton, New Jersey 08625(609) 826-7100 medical Education Verification FormApplicant s name:_____Medical school: _____Medical school address: _____ Street City State Zip Code Country Telephone number: _____ Include area code1. Did this physician attend the medical school noted above? Yes No2. What were the applicant s dates of enrollment? _____ to _____ Month/Year Month/Year3. Did this physician graduate from this medical school? Yes No If No, please explain below: _____ _____ 4.
New Jersey Office of the Attorney General Division of Consumer Affairs State Board of Medical Examiners P.O. Box 183 Trenton, New Jersey 08625 (609) 826-7100
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