Order Form

 Every effort has been made to streamline the medical licensing process for you. In order for us to provide you with the fastest, most convenient service available, please follow the instructions below.
  1. Fill-in Physician Profile completely.
  2. Mail, e-mail, or fax a current CV. (Please date CV)
Please Call 1-888-551-2140 with questions.

Please provide the following information:

Name
Birth Date
Birth Place
SSN#
Degree
Specialty
Organization
*Use if mailing address is other than your home address.
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Fax
E-mail
Other Names Used
US Citizen  Yes   No
Sex   Male Female
Height
Weight
Hair Color
Eye Color
 
Please list the states for which you are ordering licenses
STATE(s)
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
  Accelerated Standard Launch Only
To see how Accelerated and Standard compare, click here.

Examinations
Please select all that apply:

Date* Attempts Location
Date* Attempts Location
Date* Attempts Location
*Please enter the date you passed the exam.

International Medical Graduates Only

ECFMG Number

Please list information regarding malpractice, disciplinary action, or other unusual circumstances

Billing Information 

Card Type:             
Card Number:        
Expiration Date:       

Discover Card

By clicking the Submit button you agree to the terms and conditions herein

 

*It will take a few moments to process your order, thank you.

HOW DO YOU GET STARTED?

Simply complete this short
and fax or or e-mail a copy of your CV to:

Fax
801-612-0599

 E-mail sg@physicianlicensing.com

We’ll do the rest.