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ARIZONA MEDICAL BOARD POSTGRADUATE TRAINING VERIFICATION FORM AUTHORIZATION The Arizona Medical Board requires all applicants for licensure to obtain verification of all postgraduate training programs attended. This form must be completed by the Program Director. This is authorization to release any information in your files of record favorable or otherwise DIRECTLY to the Arizona Medical Board. Authorization may be sent via mail or fax to 9545 E Doubletree Ranch Road Scottsdale AZ 85258 or 480 551-2704. First Name Last Name Signature Date Important - Program Participation Report incomplete postgraduate years PGY separately from those that were successfully completed* If the postgraduate year is currently in progress report the expected completion date in the To field. Report internships residencies and fellowships separately. PG Year Department/Specialty Internship Residency Fellowship From To Successfully Completed mm/dd/yy Yes No In Progress Affix Training Program Seal Here This program was approved for postgraduate training during that period by the Accreditation Council for Graduate Medical Examination Education ACGME or the Royal College of Physicians and Surgeons of Canada Institution Name Name/Title Address City Phone Fax State Zip. Authorization may be sent via mail or fax to 9545 E Doubletree Ranch Road Scottsdale AZ 85258 or 480 551-2704. First Name Last Name Signature Date Important - Program Participation Report incomplete postgraduate years PGY separately from those that were successfully completed* If the postgraduate year is currently in progress report the expected completion date in the To field. First Name Last Name Signature Date Important - Program Participation Report incomplete postgraduate years PGY separately from those that were successfully completed* If the postgraduate year is currently in progress report the expected completion date in the To field. Report internships residencies and fellowships separately. PG Year Department/Specialty Internship Residency Fellowship From To Successfully Completed mm/dd/yy Yes No In Progress Affix Training Program Seal Here This program was approved for postgraduate training during that period by the Accreditation Council for Graduate Medical Examination Education ACGME or the Royal College of Physicians and Surgeons of Canada Institution Name Name/Title Address City Phone Fax State Zip. Authorization may be sent via mail or fax to 9545 E Doubletree Ranch Road Scottsdale AZ 85258 or 480 551-2704. First Name Last Name Signature Date Important - Program Participation Report incomplete postgraduate years PGY separately from those that were successfully completed* If the postgraduate year is currently in progress report the expected completion date in the To field. Report internships residencies and fellowships separately. PG Year Department/Specialty Internship Residency Fellowship From To Successfully Completed mm/dd/yy Yes No In Progress Affix Training Program Seal Here This program was approved for postgraduate training during that period by the Accreditation Council for Graduate Medical Examination Education ACGME or the Royal College of Physicians and Surgeons of Canada Institution Name Name/Title Address City Phone Fax State Zip.