Transcription of Fictitious Name Permit Application
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Example: dental hygienist
Fictitious Name Permit Application
Revised (08/2013) 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2382 (800) 633-2322 Fax: (916) 274-6181 BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY - Department of Consumer Affairs EDMUND G. BROWN JR., Governor MEDICAL BOARD OF CALIFORNIA Licensing Program Application CHECKLIST FOR Fictitious name Permit For all applications , did you: __ include a check for $50? __ indicate if you have additional practice locations? (Box 1) __ indicate the name for which you are applying? (Box 3) __ provide a translation or explanation of any foreign or non-standard English word to appear in the Permit name ? __ include ORIGINAL signatures? (Box 5 or Box 7) In addition, please be sure to complete the rest of the steps as listed below, depending on what kind of business is applying: If applying as a Corporation, did you: __ include a copy of your original endorsed Articles of Incorporation?
(a) Any physician and surgeon or any doctor of podiatric medicine, as the case may be, who as a sole proprietor, or in a partnership, group, or professional corporation, desires to practice under any name
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