Application - Podiatrist

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Applicant Information

Submission Date: 11/19/2019

Affidavit and Authorization for Release of Information

Please download, complete, and then sign this form in the presence of a notary public. Send the notarized affidavit to:

WV Board of Medicine
101 Dee Drive, Suite 103
Charleston, WV 25311
You are required to submit a recent photograph with the above form. The photograph must be:
  • Studio quality
  • A close-up front view of head and shoulders (not a profile)
  • A photo of an individual (no group photos will be accepted)
  • Taken within the last 6 months

I hereby declare under penalty of perjury under the laws of the State of West Virginia, that the photo of myself, was taken on or about:


Height (in feet and inches):