This application is an official form document of the State of Louisiana. Submission of this application to the Louisiana State Board of Medical Examiners (LSBME), constitutes filing this document with an agency of the State of Louisiana and/or a public official. Applicant is responsible for all information recorded on the application. The applicant is presumed to have personally completed, read and signed the application. Cause for non-issuance of a license, as well as the revocation, suspension and/or other action against a licensee, includes
Fraud, deceit or perjury in obtaining any diploma, license, permit, certification and/or registration
Providing false testimony before the Board and/or providing false sworn information.
Filing false statements with the LSBME may constitute a criminal offense, among other violations, under Louisiana law.
Forms provided by and/or authorized by this agency are the only forms that are accepted by this agency.
The answers to all questions must be typewritten or block print except as otherwise provided.
By signing this application, applicant swears and/or affirms that the information filed with the LSBME is true and correct.