Transcription of MEDICAL BOARD Licensing Program
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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY - Department of Consumer Affairs EDMUND G. BROWN JR., Governor MEDICAL BOARD OF CALIFORNIA Licensing Program 07A-100 (Revised 6/2017) 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2382 (800) 633-2322 FAX: (916) 263-2487 APPLICATION TYPE OF APPLICATION MBC Use Only Application Type Priority Review Legal Name SSN/ITIN DOB Gender Address of Record Confidential Address Telephone Numbers Email Military (Check One) or Canadian MEDICAL School Graduate International MEDICAL School Graduate (Check All That Apply) Physician s and Surgeon s License Postgraduate Training Authorization Letter (PTAL) Update Application: File #_____ Limited Practice License PRIORITY REVIEW & EXPEDITED LICENSURE Honorably Discharged Veterans of the Armed Forces - Must supply satisfactory evidence to the BOARD that you have served as an active duty member of the Armed Forces of the United States and were honorably discharged.
OF CALIFORNIA MEDICAL BOARD Licensing Program 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815-5401 Phone: (916) 263-2382 Fax: (916) 263-2487
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