Postgraduate Training Authorization Letter

Medical Board of California - PTAL Application Forms

Application Information for a Postgraduate Training Authorization Letter (PTAL)

This form package includes the application, checklist, fee schedule, live scan information, translation instructions, and supporting forms required for international medical school graduates.

Contact Information

Medical Board of California, Licensing Program

2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-5401

Phone: (916) 263-2382    Fax: (916) 263-2487    www.mbc.ca.gov

Application / Update Selection

Priority Review Legal Name SSN/ITIN DOB/Gender Address of Record

Confidential Address Telephone Numbers Email Military

Personal Information

Legal Name:

Other Names/Alias:

SSN or ITIN: SSN ITIN

Date of Birth: Gender: Male Female

Address of Record:

Telephone Numbers:

E-mail Address:

Yes/No Questions

Have you served or are you currently serving in the military? Yes No

Are you requesting expediting as a spouse or domestic partner of an active duty member? Yes No

Previous Application or License

Have you ever filed an application for a Physician’s and Surgeon’s License or PTAL in California that has been withdrawn, abandoned, or denied? Yes No

Have you previously held a Physician’s and Surgeon’s License in California? Yes No

If yes, license number: Expired:

Examinations

Are you certified by the Educational Commission for Foreign Medical Graduates? Yes No

List examinations taken and passed:

Medical Education

List each medical school attended and the medical school of graduation:

Postgraduate Training Programs

Have you participated in any ACGME-accredited postgraduate training programs in the United States or RCPSC-accredited postgraduate training in Canada? Yes No

Medical License History

Have you ever held or do you currently hold a medical license in any U.S. state, territory, or Canadian province? Yes No

ABMS / Malpractice / Disciplinary History

Are you currently certified by a Member Board of the American Board of Medical Specialties? Yes No

Has a claim or action ever been filed against you for practice of medicine that resulted in a malpractice settlement, judgment, or arbitration? Yes No

Criminal Record History

Have you ever been convicted of, or pled guilty or nolo contendere to any offense? Yes No

Practice Impairment or Limitations

Have you ever participated in a drug, alcohol, or substance abuse recovery program or impaired practitioner program? Yes No

Photograph and Declaration

Sign Legal Name: Date:

Notary Section

Signature of Applicant:

State: County:

Subscribed and sworn to before me on this day of 20

By:

Explanation for Application Question

This form may be used to provide a detailed written explanation for any "yes" response.

Legal Name:

Date of Birth: U.S. SSN or ITIN:

Application Question Number:

Sign Legal Name: Date:

Timeline of Activities

Provide a complete chronological timeline from graduation to present, including professional and non-professional activities.

Sign Legal Name: Date:

Certificate of Medical Education

Check one: U.S. or Canadian Medical School Graduate International Medical School Graduate

Legal Name:

Date of Birth: Last 4 Digits of U.S. SSN or ITIN:

Medical School of Graduation:

Name of Medical School:

State/Province/Country:

Years of resident instruction:

Certificate of Completion of ACGME/RCPSC Postgraduate Training

Facility Name:

Facility Address:

Specialty: ACGME 10-digit Program #:

Dates of Training: Start Date: End Date:

Certificate of Clinical Training

Clinical Subject:

Facility Name:

City/State/Province/Country:

Dates of Attendance: Weeks or Weekly Clinical Hours:

Medical School Official Certification:

Printed Name of School Official:

Title of School Official:

Signature of School Official: Date:

Certificate of Individual Clinical Clerkship Training:

Facility Name:

Facility Address:

Clinical Specialty:

Dates of Training:

Affiliated with medical school? Yes No

Name of the affiliated medical school:

ACGME accredited residency program? Yes No

ACGME 10-digit program #: Specialty:

Printed name of program director or clinical instructor:

Signature of program director or clinical instructor: Date:

Submission Notes

- All required forms must be completed and mailed directly from the appropriate source to the Board.

- Yes responses generally require a signed and dated written explanation.

- Live Scan and fingerprint processing fees are separate from application fees.