State Medical Board Forms

For medical license applicants requiring clerkship verification from Kingsbrook:
- Fill out and submit form below for each clerkship to be verified.
- Send copy of transcript via email to UME.
Due to the number of requests we receive, please understand that processing may take up to sixty days.
All information will be verified with our records and may be cross referenced with the applicant's medical school.
Affiliation agreements and other supporting documents are proprietary
and may only be shared with the medical school and/or the state medical board with the appropriate permissions.

First Name
Last Name
Email Address
Medical School
Phone Number
Clerkship (only one)	Submit form again for another clerkship
Licensing State
File Number
Analyst Name (last, first)
Analyst Phone Number
Analyst Email Address

Date: 1/22/2019 6:01:44 AM   |   IP 34.224.102.60

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Kingsbrook Undergraduate Medical Education. U.S. Hospital Clinical Clerkships. Accreditation Council for Graduate Medical Education Core Competencies: Patient Care. Medical Knowledge. Professionalism. Systems-based Practice. Practice-based Learning. Interpersonal and Communication Skills.

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