Medical Board Application Form

Medical Board Application Form and Professional Services Agreement

WHEREAS

WHEREAS, the Board Name: (hereinafter "Board") is authorized to receive and review applications for licensure and to engage professional services for review and advisory functions; and

WHEREAS, Applicant Name: seeks licensure, credentialing, or engagement in professional services and submits this application and agreement to the Board for consideration and potential contracting of services; and

WHEREAS, the parties desire to set forth the scope, payment, confidentiality, term, and other material terms applicable to any professional services provided by Applicant to the Board in connection with application review or related matters.

Applicant Information

Professional Credentials and Training

Licensure, Certification, and History

Have you ever had a license denied, revoked, suspended, limited, or subject to probation? Yes No

Have you ever been named in a malpractice claim or settlement? Yes No

Scope of Work

Describe the professional services, duties, and responsibilities Applicant will perform if engaged by the Board. Include deliverables, timelines, and any limits on authority.

Payment Terms

Compensation Amount:

Late fee for overdue payments (percentage or flat amount):

Term and Termination

Effective start date:    Term end date:

Either party may terminate this agreement for convenience upon written notice to the other party delivered not less than days prior to termination. Termination for cause may be immediate upon notice if a material breach occurs.

Confidentiality

The parties acknowledge that during the provision of services, each may receive or have access to confidential information. Each party shall: (a) use confidential information solely for performance of obligations under this agreement; (b) limit disclosure to employees, agents, or contractors with a need to know and under obligations of confidentiality; and (c) take reasonable steps to protect such information from unauthorized disclosure. Confidential information does not include information that is or becomes public through no fault of the receiving party or that is independently developed without use of confidential information.

Applicant acknowledges and agrees to maintain confidentiality and protect patient-identifiable information in compliance with applicable law and professional standards.

I acknowledge the confidentiality obligations above: Applicant acknowledges

Governing Law

This agreement and any dispute arising out of or relating to it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

Entire Agreement

This document, together with any exhibits or attachments expressly incorporated, constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior and contemporaneous agreements, understandings, representations, and warranties, whether written or oral. Any amendment or modification must be in writing signed by both parties.

Certification and Attestation

I certify under penalty of perjury that the information provided in this application is true, correct and complete to the best of my knowledge. I understand that false statements, omissions, or misrepresentations may result in denial of licensure, disciplinary action, or other legal consequences.

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