Physician Assistant Application for Licensure …

PROOFNew Jersey Office of the Attorney GeneralDivision of Consumer AffairsState Board of Medical ExaminersPhysician Assistant Advisory Committee140 East Front Street, 3rd Floor, Box 183 Trenton, New Jersey 08625(609) 826-7100 Assistant Application for Licensure ChecklistUse this checklist as a guide to assure your Application is complete. Applicant s name:_____ I. Application A. Answer each question completely. B. Be sure to have the Application notarized. C. Attach one (1) passport photograph (2 x 2 ) to the Application . D. Provide a valid daytime telephone number (include area code). E. Attach additional documents (if applicable).

PROOF. Checklist. III. Transcripts: Verification of Education A. Physician Assistant Program IV. Curriculum Vitae V. Application Fee Personal check or money order payable to the Physician Assistant Advisory Committee, in the amount of

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