Ga. Comp. R. & Regs. R. 360-40-.03 - Applicants Applying for Licensure to Georgia through IMLC
* Your current CV or resume (also, provide information for any date gaps in the CV or resume)
* Form B, Reference Form (three references are required)
* Form D, Affidavit of Applicant
* Form D2, Affidavit for Medical Board License
* A copy of a secure and verifiable document from the list following Form
* Form E, Malpractice Questionnaire, including documentation of any cases
* National Practitioner Data Bank (NPDB) and Health Integrity and Protection Data Bank (HIPDB) Self-Query and Reports, if you have ever held a license in the US or Canada (not including training licenses). Order it at https://www.npdb-hipdb.hrsa.gov/ext/RulesOfBehaviorSQ.jsp?SUBJECT_TYPE=I.
* Military discharge documentation, if you have ever been discharged from US military service.
* Form G, Specific Power of Attorney, if you want to authorize anyone else to make inquiries about your application.
Notes
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