Form Mdc1 PDF Details

Form Mdc1 is an important form that must be filled out by all business owners in Maryland. The form is used to report income, wages, and other information related to the company. Anyone who fails to file this form may face penalties, so it's important to make sure it is filled out correctly. This blog post will provide a detailed overview of Form Mdc1 and explain how to complete it accurately.

If you would like first find out how much time you need to prepare the form mdc1 and how many pages it has, here is some general data that might be helpful.

QuestionAnswer
Form NameForm Mdc1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

MDC1

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

M.D. Conferral

Office of the Professions

Division of Professional Licensing Services

 

www.op.nysed.gov

 

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)

2

Month

Day

Year

3. Birth Date

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

State

 

 

Zip Code

 

 

 

 

Country/

Province

65. Telephone/E-Mail Address

Daytime phone

Area Code

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: _______ / _______ / _______

mo.

day

yr.

New York State limited medical license number: __________________________________ Date issued: _______ / _______ / _______

mo.

day

yr.

MDC1, Page 1 of 2 (Rev. 10/08)

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.

Since you last registered, have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime

 

(felony or misdemeanor) in any court?

Yes

No

109.

Since you last registered, are criminal charges pending against you in any court?

Yes

No

11

10.

Since you last registered, are charges pending against you in any jurisdiction for any sort of professional misconduct?

Yes

No

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

to professional misconduct, unprofessional conduct, incompetence, or negligence?

Yes

No

NOTE: If you answer "Yes" to any questions numbered 8-12, submit a letter giving a complete detailed explanation. Include copies of any court records (conviction records), and if you possess one, a copy of the "Certificate of Relief from Disabilities" or your "Certificate of Good Conduct."

1312.

ATTESTATION

I certify that the statements made in this application and any accompanying documentation are true, complete and correct. I understand that any misrepresentation or any false or misleading information made in connection with my application may result in criminal prosecution and may be cause for disciplinary action, including the loss of my license and that the willful failure to register while continuing to practice my profession constitutes professional misconduct.

__________________________________________________________________________

_________________________________

Signature

Date

In this space

securely attach

photograph taken

within the past year.

Write signature on light portion of photograph, not across features

Date of Photo _______ / _______ / _______

Mail this form and the required $300 fee to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Certification and Verification Unit, 89 Washington Avenue, Albany, NY 12234-1000. DO NOT

SEND CASH. Make check or money order payable in U.S. funds to the New York State Education Department

MDC1, Page 2 of 2 (Rev. 10/08)

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