Application - Podiatrist

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Applicant Information


First Name:	Middle Name:	Last Name:	Suffix (Jr., Sr., III, etc.):
Submission Date:	12/21/2024
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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