INITIAL APPLICATION: INSTRUCTIONS- TEMPORARY POSTGRADUATE TRAINING PERMIT REVISED: 2/2017 P a g e | 1 of 2
2017-2018 INITIAL APPLICATION
GEORGIA RESIDENCY TRAINING PERMIT
The Georgia Composite Medical Board will discuss the application status with the applicant and
Program Director/GME Designee ONLY associated with the temporary training permit.
Once an application for a residency-training permit has been received, staff must complete the
initial review within 30 days. Notification is sent in writing to the GME Office with the application
status and an itemized list of documents needed to complete the file (if required.)
CHECKLIST
_______ Complete Application Pages 1-2
On page 1 – If you don't have a US Social Security Number, you may leave it blank for now. If your
new visa documentation is not yet available, submit what you have with the permit application packet
and forward your updated visa documentation as soon as it is received. The state board will process
your application and place it on pending status until your relevant visa documentation is received.
On page 2 – If any YES answers, provide appropriate statement(s)/documentation. Each “Yes”
answer requires a written statement explaining the circumstances. Attach your explanation and
copies of any official documentation. Examples include: arrest record, final disposition of arrest, or
treating physician documentation. Previous residency completion certificate or letter of good
standing can be obtained from your program coordinator. Make sure all documents are LEGIBLE.
_______ Complete Page 3 - Form A - Affidavit of Applicant Form. Original signatures required. Form must
be notarized and the Applicant Date and the Notary Date MUST match. A passport-sized/type photograph is
required.
_______ Complete Page 4 - Form A1 – Notarized Affidavit for Medical Board License Form. Submit the
appropriate documentation to show lawful presence in the US. Original signatures required. This form must
also be notarized.
_______ Complete the top portion of Page 5 - Form B - Certificate of Postgraduate Training Form. Fill out
Part 1 only. Include the completed form and attachments in your return package. Your incoming program
will complete Part 2 and take care of the program director signature.
_______ Submit a copy of your medical school or osteopathic school diploma – must be approved by
the ACGME, AOA, or the LCME. (Provide English translation, if diploma is not in English.) If a copy of the
diploma is not yet available, a letter from the school (on letterhead) with the expected date of graduation can
be accepted.
OR
_______ Submit a copy of your ECFMG certification if you are a graduate of a foreign medical school. If a
copy of the ECFMG certificate is not yet available, a request for a waiver must be submitted. Click this link
http://medicalboard.georgia.gov/petition-and-waiver-rules-information
Use only blue or black ink to complete the forms. No corrections, strike-through or white-outs are
allowed. If you make a mistake access the online Orientation page and print a new form.
NOTE:
If you already have a full Georgia Medical License, you do not need to complete this renewal. Have
your program coordinator notify GME with your license information.
If you are currently applying for a full license, you should complete the renewal form in case your full
license is not received by 7/1/2017. Attach a note to inform GME about the license application.
INITIAL APPLICATION: INSTRUCTIONS- TEMPORARY POSTGRADUATE TRAINING PERMIT REVISED: 2/2017 P a g e | 2 of 2
Documentation to be submitted with the Notarized Affidavit:
If you are a U.S. citizen, provide ONE of the following:
Copy of your Current Driver’s License
Copy of your current U.S. passport
Copy of your Naturalization Certificate
If you are NOT a U.S. citizen, provide the following:
Permanent Resident card – copy of the I-551 (Both FRONT and BACK of card)
Employment Authorization Card - copy of the I-766 or I-688A
J-1 Visa – copy of the DS-2019 (J-1 visa) and copy of the I-94
F-1 Visa – Copy of the I-20 (F-1 visa) and copy of the I-94
H-1-B visa – Visa Information with valid (not expired) foreign passport and I-94
The Board participates in the DHS-USCIS SAVE (Systematic Alien Verification for
Entitlements or "SAVE") program for the purpose of verifying citizenship and immigration
status information of non-citizens.
MAKE SURE ALL COPIES ARE LEGIBLE. Use a good quality copier and ENLARGE the
size of the copy if needed. If we cannot read your documents, we will be unable to submit
your information to the SAVE program, which will delay the processing of your application.
INITIAL APPLICATION: TEMPORARY POSTGRADUATE TRAINING PERMIT FORM REVISED: 2/2017 P a g e | 1 of 5
APPLICATION FOR TEMPORARY POSTGRADUATE TRAINING PERMIT
BASIC INFORMATION
INSTRUCTIONS: Provide your full legal name, in the format indicated on the application. This is the name that will be
printed on the permit card and reported to hospitals and those who inquire about your training permit.
LAST NAME
FIRST NAME
MIDDLE NAME
MAIDEN NAME (IF APPLICABLE)
DEGREE (MD OR DO)
Other names under which material may be submitted – Do not use nicknames
NAME OF MEDICAL SCHOOL
GRADUATION DATE
Will you be participating in a short-term elective ROTATION OR are you a VISITING RESIDENT? ______YES ______NO
If YES, please provide a letter of good standing from your current program director.
US Social Security Number:
-
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This information is authorized to be obtained and disclosed to state and federal agencies by O.C.G.A. § 19-11-1 and O.C.G.A. § 20-3-295, 42 U.S.C.A.
§ 651 and 20 U.S.C.A. § 1001. This information also may be disclosed to the National Practitioner’s Data Bank (NPDB) or other state medical boards
or regulatory agencies for license tracking purposes.
I am a U.S. Citizen
NOTE: SUBMIT WITH THIS APPLICATION YOUR ORIGINAL NOTARIZED AFFIDAVIT (FORM A1) and VERIFIABLE
DOCUMENT.
I am not a U.S. Citizen, but am a qualified alien under the Federal Immigration and Naturalization Act, and I am
lawfully present in the United States.
NOTE: SUBMIT WITH THIS APPLICATION YOUR ORIGINAL NOTARIZED AFFIDAVIT (FORM A1) and APPROPRIATE
ACCEPTABLE SUPPORTING DOCUMENTATION.
The processing of your application may be delayed due to verification requirements.
FOR TEMPORARY TRAINING PERMIT HOLDERS, YOUR GEORGIA GME PRACTICE ADDRESS WILL BE USED AS THE
PRIMARY MAILING ADDRESS TO RECEIVE MAIL FROM THE BOARD.
RESIDENCE STREET ADDRESS
APARTMENT #
CITY
STATE
ZIP CODE
COUNTY
(AREA CODE) PHONE NUMBER
(AREA CODE) FAX NUMBER (OPTIONAL)
E-MAIL ADDRESS (OPTIONAL)
Georgia GME Practice Address
(MANDATORY)
Graduate Medical Education,
Emory University School of Medicine
100 Woodruff Circle
SUITE #
327
CITY
Atlanta
STATE
GA
ZIP CODE
30322
COUNTY
DeKalb
(AREA CODE) PHONE NUMBER
(AREA CODE) FAX NUMBER (OPTIONAL)
E-MAIL ADDRESS (OPTIONAL)
INITIAL APPLICATION: TEMPORARY POSTGRADUATE TRAINING PERMIT FORM REVISED: 2/2017 P a g e | 2 of 5
NAME:_____________________________ SS#:___________________________
PRINT LEGIBLY
TEMPORARY POSTGRADUATE TRAINING PERMIT
If you answer, “YES” to any of the questions, you are required to furnish complete details, including date, place, reason
and disposition of the matter. This includes items such as a statement from the treating physician, court
documents, etc. For Questions 20-22, a letter of good standing/explanation from previous GME
program(s) is required. Failure to furnish the documentation may result in a delay in the application process.
YES NO
1. During the last 7 years, have you suffered from any physical, psychiatric, or substance use disorder that could
impair or require limitations on your functioning as a professional or has resulted in the inability to practice
medicine for more than 30 days, or required court-ordered treatment or hospitalization? (If yes, provide
treatment history documentation to include diagnosis, treatment regimen, hospitalization, and ongoing
treatment/medication to the Board.
NOTE: If you are currently enrolled in GAPHP, you may check NO.
2. Have you ever entered a plea bargain, been arrested, indicted or convicted for violating any state or federal
law including DUI (excluding minor traffic violations)? As used in this question, the term "conviction" shall
include a finding or verdict of guilt, or a plea of guilty, or a plea of nolo contendere in a criminal proceeding,
regardless of whether the adjudication of guilt or sentence is withheld or not entered.
3. Have you ever been denied the privilege of taking an examination given by any licensing Board or agency?
4. Has any licensing Board or agency ever denied you a certificate or a license?
5. Has any licensing Board or agency ever refused you renewal of a certificate or a license?
6. Have you ever been denied a DEA registration number?
7. Have you ever been issued a restricted DEA registration?
8. Are you currently registered with the DEA? (DO NOT INCLUDE INSTITUTIONAL DEA #)
If you are registered with the DEA, provide the number and state of issue below:
_____________________ State of issue_______________________
9. Have you ever had any malpractice suits filed against you?
10. Have you ever been denied membership in or in any way sanctioned by any medical or osteopathic
association, society, or specialty society?
11. Have you ever resigned from a hospital staff position or training program after a complaint or peer review
action has been initiated against you?
12. Have you ever voluntarily surrendered a medical license?
13. Have you ever voluntarily surrendered a controlled substance registration?
14. Have you ever voluntarily surrendered a DEA registration?
15. To your knowledge, are you the subject of an investigation by any licensing Board or agency as of the date
of this application?
16. Do you have any applications for licensure pending before any other licensing Board or agency?
17. Have you ever had any restrictions as a Medicaid or Medicare provider?
18. Are you in default on a state or federally funded and/or guaranteed school loan?
19. Are you in default on child support payments?
20. Have you ever transferred from one graduate medical education program to another? If yes, attach
documentation.
21. Have you ever been terminated from a graduate medical education program? If yes, attach
documentation.
22. Have you ever resigned from a graduate medical education program? If yes, attach documentation.
INITIAL APPLICATION: TEMPORARY POSTGRADUATE TRAINING PERMIT FORM REVISED: 2/2017 P a g e | 3 of 5
NAME:________________________________________________________ SS#:___________________________________
PRINT LEGIBLY
FORM A
Temporary Postgraduate Training Permit
A F F I D A V I T O F A P P L I C A N T
T O P O F P H O T O
( H E A D )
BOTTOM OF PHOTO (SHOLDERS)
Notice: All items in this application are mandatory; none are voluntary.
Failure to provide any of the requested information will delay the
processing of your application. The information provided would be used
to determine your qualifications for a temporary postgraduate training
permit per Georgia Law that authorizes collection of this information.
The information on your application may be transferred to other medical
licensing authorities the Federation of State Medical Boards or other
governmental or law enforcement agencies.
I acknowledge and state that I have read the Application for Temporary Postgraduate Training Permit Information and Applicant Instructions that accompanied
this application and I have answered all questions in compliance with these instructions. I acknowledge that it is my responsibility to read and become familiar
with the Medical Practice Act and the Board Rules, copies of which are sent to applicants.
I further state that by filing this application for a temporary postgraduate training permit to practice medicine in the State of Georgia; I hereby authorize and
consent to have an investigation made as to my moral character, professional reputation and fitness for the practice of medicine. I agree to give any further
information, which may be required in reference to my past record. I understand that I will not receive a copy of the report or know its content and I further
understand that the contents of the investigative report will be privileged unless determined otherwise by the Board or Court Order.
I request and authorize any treatment program to release alcohol and drug abuse patient records to the Georgia Composite Medical Board for the purpose of
evaluating my fitness to practice. The consent of this paragraph is subject to revocation pursuant to federal regulations and terminates upon the date of
termination of my training permit in Georgia.
I authorize and request every person, hospital, clinic, community, governmental agency (local, state, federal or International), court, association, institution, or
other organization having control of my documents, records and other information pertaining to me, to furnish to the Georgia Composite Medical Board any such
information, including documents, records regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data
and to permit the Georgia Composite Medical Board or any of its agents or representatives to inspect and make copies of such documents, records, and other
information, in connection with this application, subsequent licensure or practice there under.
I authorize and request the Georgia Composite Medical Board to obtain any criminal history information concerning me from any authorized law enforcement
agency, including but not limited to the Georgia Crime Information Center (GCIC) and the National Crime Information Center (NCIC).
I hereby release to the Board, its staff and their representatives, any and all documentation necessary now and in the future to evaluate my qualifications to
practice medicine, including, but not limited to my moral character, professional reputation and fitness to safely practice medicine.
I hereby release, discharge, and exonerate the Georgia Composite Medical Board, its agents or representatives, and any person so furnishing information, from
any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records or other information or the investigation made
by the Georgia Composite Medical Board.
I authorize the Georgia Composite Medical Board to release information, material, documents, or the like relating to me or to this application to any other State or
Territory of the United States or Province of Canada, a law enforcement agency, hospital or other appropriate agencies as determined by the Georgia Composite
Medical Board.
I hereby swear or affirm under penalties of perjury that all statements made by me in this application and any attachments hereto and made a
part hereof are true and correct. I understand that pursuant to the Official Code of Georgia Annotated, Section 43-34-46, any person who shall give false or
forged evidence of any kind to the Board in connection with an application for a license to practice medicine shall be guilty of a felony and upon conviction
thereof, shall be punished by a fine of not less than $500.00 nor more than $1,000.00, or by imprisonment from two to five years, or both.
I understand that I must limit my activities under the training permit to such acts as may be prescribed by or incidental to the training
program, that I may train only under the supervision of physicians responsible for supervision as part of the training program, and may
practice in facilities affiliated with the program only if such practice is part of the training program.
SIGNATURE OF APPLICANT
DATE
CITY
COUNTY
STATE
PRINTED NAME OF APPLICANT
_________________________________
Being duly sworn, says that he/she is the person who executed the above
application for a temporary postgraduate training permit in the State of
Georgia; and that all the statements herein contained are true in every
respect and that the attached photo is a true photo of the applicant. In
addition, I will immediately notify the Board in writing of any changes to
the answers to questions contained in the Applicant Questionnaire if such a
change in answer is warranted at anytime, prior to being granted a
temporary postgraduate training permit by the Georgia Composite Medical
Board.
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Sworn and subscribed to me this _______day of ___________________, 20______.
____________________________________________________(Notary Public)
My Commission Expires
______________________
PHOTO AREA
PASTE A 2 ¼” X 3”
PHOTO HERE.
PHOTO MUST BE OF
YOUR HEAD
AND SHOULDER AREAS ONLY
INITIAL APPLICATION: TEMPORARY POSTGRADUATE TRAINING PERMIT FORM REVISED: 2/2017 P a g e | 4 of 5
FORM A(1)
O.C.G.A. § 50-36-1(e)(2) Affidavit for Medical Board License
Name of Resident: _____________________________________________
PRINT LEGIBLY
Institution Name: ______Emory University School of Medicine________
Residency Program Name (Enter your Incoming Emory Program Name): ______________________
By executing this affidavit under oath, as an applicant for a professional license, as referenced in O.C.G.A. § 50-36-
1, from the Georgia Composite Medical Board, the undersigned applicant verifies one of the following with respect
to my application for a public benefit: (SELECT ONLY ONE.)
1. _________ I am a United States citizen.
2. _________ I am a legal permanent resident of the United States.
3. _________ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an
alien number issued by the Department of Homeland Security or other federal immigration agency. My alien
number issued by the Department of Homeland Security or other federal immigration agency is:
___________________________________________________________________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one
secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.
REQUIRED: The secure and verifiable document provided with this affidavit can best be classified as:
____________________________________________________________________________________________.
U.S. citizens – U.S. passport, driver’s license, or certificate of naturalization
NON-US citizens - I-551, I-766/I-688A, J-1 visa, F-1 visa, H1B visa, I-94 – all that apply
In making the above representation under oath, I understand that any person who knowingly and willfully makes a
false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. §
16-10-20, and face criminal penalties as allowed by such criminal statute.
Executed in _________________________________________ (city), __________________(state).
Residency Training Permit __________________________________________
1114 – License Type Signature of Applicant
________________________________________
Printed Name of Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
________ DAY OF _______________________, 20_________
__________________________________
NOTARY PUBLIC My Commission Expires: ____________________
INITIAL APPLICATION: TEMPORARY POSTGRADUATE TRAINING PERMIT FORM REVISED: 2/2017 P a g e | 5 of 5
This section must be completed by the Program Director (Incoming Program) who is licensed in Georgia.
PROGRAM DIRECTOR’S AFFIDAVIT
I hereby recommend the above applicant be granted a postgraduate training permit. I hereby certify that he/she will limit his/her practice to such acts as may be
prescribed by or incidental to the training program, that he/she may train only under the supervision of physicians responsible for supervision as part of the training
program and may practice in facilities affiliated with the program only if such practice is part of the training program for which the permit is granted. I hereby
recommend the above applicant be granted a postgraduate training permit. I hereby certify that he/she will limit his/her practice to such acts as may be prescribed
by or incidental to the training program, that he/she may train only under the supervision of physicians responsible for supervision as part of the training program
and may practice in facilities affiliated with the program only if such practice is part of the training program for which the permit is granted. I understand that I
must report to the Board the following within 15 days of the event: any disciplinary action taken against the permit holder for any ground or violation
enumerated in O.C.G.A. §§ 43-34-37 and 43-1-19, the permit holder’s withdrawal or termination from or completion of a postgraduate training program
or the permit holder leaving the program for any length of time in excess of two weeks. I HEREBY RECOMMEND THE ABOVE APPLICANT FOR
ADVANCEMENT TO THE NEXT LEVEL AS REQUIRED IN 360-2-.12(4).
FORM B
CERTIFICATE OF POSTGRADUATE TRAINING FORM
INSTRUCTIONS: Complete all items, including all required documentation, signatures, and seals.
PART 1: To be completed by the Applicant
LAST NAME FIRST NAME MIDDLE INITIAL
DATE OF BIRTH
TELEPHONE NUMBER
HOME: WORK:
GEORGIA GME PRACTICE ADDRESS:
Graduate Medical Education, Emory University School of Medicine, 100 Woodruff Circle, Suite 327
CITY
Atlanta
STATE
GA
ZIP CODE
30322
PART 2: To be completed by the Incoming Program Director
TYPE OF PROGRAM: CIRCLE THE YEAR OF TRAINING
PGY1
PGY2
PGY3
PGY4
PGY5
PGY6
PGY7
Name of Training Program (i.e., Internal Medicine, Psychiatry) _________________________________________________________
Beginning date of training in GA program:
Projected Completion Date in GA program:
Please type or print:
Program Director’s Name Title
_____________________________________________________________ _____________________________________________________
Signature Date
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Sworn to and subscribed before me this
___________ day of __________________________, 20________.
DATE MONTH YEAR
SIGNATURE OF NOTARY PUBLIC
EXPIRATION STAMP must be stamped here