Application - Podiatrist

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If you will be away from your computer for any period of time after starting your online application, it is strongly advised that you click on the "Save for Later" button located at the bottom of each page to minimize the risk of losing the data that you have input into the system. You can then log in to complete your saved application at a later time.

Applicant Information


First Name:	Middle Name:	Last Name:	Suffix (Jr., Sr., III, etc.):
Submission Date:	4/26/2024
Maiden Name:	Alternate Names:
Social Security Number:	Place of Birth:		Date of Birth:

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:

Identification


Gender:	Color of Hair:	Color of Eyes:


Height (in feet and inches):
Feet:	Inches:	Weight:

Identifying Marks:

Application - Podiatrist

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