Transcription of MEDICAL BOARD Licensing Program
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MEDICAL BOARD Licensing Program
OF CALIFORNIA MEDICAL BOARD Licensing Program 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815-5401 Phone: (916) 263-2382 Fax: (916) 263-2487 07A-100 (Revised 6/2018) Protecting consumers by advancing high quality, safe MEDICAL care. Governor Edmund G. Brown Jr., State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs CERTIFICATE OF CLINICAL TRAINING (This form is only required of international MEDICAL school graduates) Type or Print Legibly APPLICANT INFORMATION MBC Use Only Applicant Information School Seal Signature and Date LEGAL NAME: Last First Middle Suffix Date of Birth (m/dd/yyyy) Last 4 Digits of SSN or ITIN MEDICAL School of Graduation MEDICAL SCHOOL.
www.mbc.ca.gov INFORMATION AFFIX MEDICAL Staff Clinical Hours L5 Licensing Program . MEDICAL BOARD . 2005 Evergreen Street, Suite 1200 . Sacramento, CA 95815- 5401
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