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MEDICAL BOARD Licensing Program

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.

NOTE: To be eligible for a PTAL or License, all schools attended must be on the Board’s list of recognized or approved medical schools. If you did not attend or graduate from a …

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