Training Program Verification Form - Physician Assistant ...

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Training Program Verification Form - Physician Assistant ...

  1. 1. Charlie Crist Ana M. Viamonte Ros, M.D.,M.S.H. Governor State Surgeon General PHYSICIAN ASSISTANT PROGRAM VERIFICATION FORM To: From: Department of Health Council on Physician Assistants 4052 Bald Cypress Way Bin #C03 Tallahassee, Florida 32399-3253 (Physician Assistant program address) The individual listed below has applied to the Florida Department of Health, Council on Physician Assistants for licensure as a physician assistant. A diploma from your school was submitted as proof of having completed educational prerequisites for licensure in Florida. Please authenticate by signature and seal that the following is true and correct to your records. Name: _______________________________________________________________ First Middle Last SS#: - - DOB: / / Profession Physician Assistant Degree issue / / : date: Comments (if any):______________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _________________________________________ Verified by: (signature) _________________________________________ SEAL Name: (please print) _________________________________________ Title: 4052 Bald Cypress Way, Bin #C03, Tallahassee, FL 32399-3253

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