Form Mdc1 – Fill Out and Use This PDF

Application for Conferral of M.D. Degree

by Board of Regents

Requirements and Instructions

1.To be eligible, you must have completed a medical education program in a foreign medical school satisfactory to the department which does not grant the degree doctor of medicine (M.D.) and in which the philosophy and curriculum were equivalent, as determined by the department, in accordance with the policy of the Board of Regents, to those in programs leading to the degree of doctor of medicine (M.D.) at medical schools in the United States satisfactory to or registered by the Board of Regents and the department.

and

Hold a license to practice medicine in New York State in accordance with provisions of section 6524 or 6528 of the Education Law or their equivalent as determined by the Regents pursuant to their authority under section 6506 of the Education Law.

2.Complete this application and submit the entire form along with the required fee of $300 to the New York State Education Department at the address at the end of the form. Be sure to sign and date item 13.

Important Note: Do not send cash. The required fee of $300 must be submitted with this application. Make check or money order in U.S. funds payable to the New York State Education Department.

Department Use Only

60 $300 CD

61 $300 CD

Certificate Number

Conferral Date

Initials

1

2. Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

43. Print Name Exactly as It Appears on Your License

Last

First

Middle

54. Mailing Address (You must notify the Department promptly of any address or name changes.)

Line 1

Line 2

Line 3

City

Country/

Province

65. Telephone/E-Mail Address

Daytime phone

E-mail Address (please print clearly)

6

6.

Name of degree granting institution where you completed your medical education: __________________________________________

______________________________________ Degree granted: ____________________ Date granted: _______ / _______ / _______

mo.dayyr.

Address: _____________________________________________________________________________________________________

City: ________________________________ State/Province: _________________________ Country: __________________________

7

7.

New York State medical license number: ________________________________________ Date issued: _______ / _______ / _______

78.

Since you last registered, has any state other than New York instituted charges against you for professional misconduct, unprofessional conduct, incompetency or negligence, or revoked , suspended, or accepted surrender of a professional license held by you?

Yes No

89.

109.

11

10.

12

11.

Since you last registered, has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you voluntarily or involuntarily resigned or withdrawn from such association to avoid the imposition of such action due

1312.

ATTESTATION