| Application for Locum Tenens |
| Form # |
Title/Description |
| 570 |
Application to Practice Medicine and Surgery
You must also complete AMA Physician Profile Data Report. |
| 571 |
Authorization and Waiver |
| 2165 |
Certification of Post Graduate Training Not necessary if utilizing FCVS. |
| 2252 |
Convictions and Pending Charges If applicable |
| 1445 |
Disciplinary Inquiries Report Not necessary if utilizing FCVS |
| 546 |
Information for Completing Medicine and Surgery Application |
| 2829 |
Malpractice Suits or Claims Form |
| 2164 |
Medical Education Verification Form Not necessary if utilizing FCVS and does not apply for locum tenens license. |
| 1935 |
Request for Physician Profile Data Required for DO only. |
| 1934 |
Work History Medicine and Surgery |
| |
| Application For Re-registration |
| Form # |
Title/Description |
| 1542 |
Application for Re-Registration of License to Practice Medicine and Surgery
You must also complete AMA Physician Profile Data Report. |
| 571 |
Authorization and Waiver |
| 2252 |
Convictions and Pending Charges If applicable |
| 1445 |
Disciplinary Inquiries Report |
| 2167 |
Hospital, Facility and Employment Verification Form |
| 546 |
Information for Completing Medicine and Surgery Application |
| 2829 |
Malpractice Suits or Claims Form |
| 1935 |
Request for Physician Profile Data Required for DO only. |
| 1934 |
Work History Medicine and Surgery |
| |
| Application for Step 3 USMLE |
| Form # |
Title/Description |
| 570 |
Application to Practice Medicine and Surgery |
| 571 |
Authorization and Waiver |
| 2165 |
Certification of Post Graduate Training Not necessary if utilizing FCVS. |
| 2252 |
Convictions and Pending Charges If applicable |
| 2167 |
Hospital, Facility and Employment Verification Form |
| 546 |
Information for Completing Medicine and Surgery Application |
| 2829 |
Malpractice Suits or Claims Form |
| 2164 |
Medical Education Verification Form Not necessary if utilizing FCVS. |
| 1935 |
Request for Physician Profile Data Required for DO only. |
| 1934 |
Work History Medicine and Surgery |
| |
| Application for Temporary Camp Physician |
| Form # |
Title/Description |
| 568 |
Application for Temporary Camp Physician Application Packet
You must also complete AMA Physician Profile Data Report. |
| 2252 |
Convictions and Pending Charges If applicable |
| 1445 |
Disciplinary Inquiries Report Not necessary if utilizing FCVS. |
| 546 |
Information for Completing Medicine and Surgery Application |
| 2829 |
Malpractice Suits or Claims Form |
| 1935 |
Request for Physician Profile Data Required for DO only. |
| |
| Application for Temporary Education Permit |
| Form # |
Title/Description |
| 2601 |
Affidavit of Hospital Authority |
| 2329 |
Application for Renewal of Temporary Educational Permit |
| 564 |
Application For Temporary Educational Permit |
| 2252 |
Convictions and Pending Charges If applicable |
| |
| Application For Visiting Professor |
| Form # |
Title/Description |
| 570 |
Application to Practice Medicine and Surgery
You must also complete AMA Physician Profile Data Report. Go to the Requirements Section for direct link. |
| 571 |
Authorization and Waiver |
| 2165 |
Certification of Post Graduate Training Not necessary if utilizing FCVS. |
| 2252 |
Convictions and Pending Charges If applicable |
| 1445 |
Disciplinary Inquiries Report Not necessary if utilizing FCVS. |
| 546 |
Information for Completing Medicine and Surgery Application |
| 2829 |
Malpractice Suits or Claims Form |
| 2164 |
Medical Education Verification Form Not necessary if utilizing FCVS |
| 1935 |
Request for Physician Profile Data Required for DO only. |
| 1934 |
Work History Medicine and Surgery |
| |
| Application for Endorsement/Reciprocity |
| Form # |
Title/Description |
| 570 |
Application to Practice Medicine and Surgery
DO NOT complete this application if you already held a license with the State of Wisconsin. You must apply as re-registration see above listing. You must also complete AMA Physician Profile Data Report. |
| 571 |
Authorization and Waiver |
| 2165 |
Certification of Post Graduate Training Not necessary if utilizing FCVS. |
| 2252 |
Convictions and Pending Charges If applicable |
| 1445 |
Disciplinary Inquiries Report Not necessary if utilizing FCVS. |
| 2167 |
Hospital, Facility and Employer Verification Form |
| 546 |
Information for Completing Medicine and Surgery Application |
| 2829 |
Malpractice Suits or Claims Form |
| 2164 |
Medical Education Verification Form Not necessary if utilizing FCVS. |
| 1935 |
Request for Physician Profile Data Required for DO only. |
| 1934 |
Work History Medicine and Surgery |
| |
| Application for Minnesota Licensee |
| Form # |
Title/Description |
| 2862 |
Application For License to Practice Medicine and Surgery for Individuals with a Current Unrestricted Minnesota License You must also complete AMA Physician Profile Data Report. |
| 571 |
Authorization and Waiver |
| 2252 |
Convictions and Pending Charges If applicable. |
| 1445 |
Disciplinary Inquiry Report from the Federation of State Medical Boards |
| 2861 |
Information for completing Application for Individuals to Practice Medicine and Surgery with a Current Unrestricted Minnesota License |
| 2829 |
Malpractice Suits or Claims Form If applicable. |
| 1935 |
Request for Physician Profile Data Required for DO only. |