Management Branch Office of Licensing

CERTIFICATE OF COMPLETION OF ACGME/AOA/CCME POSTGRADUATE TRAINING SECTION 1 To be completed by applicant and forwarded to the facility where postgraduate training was received and/or completed. This certifies that

Full Name of Applicant

a graduate of

Full Name of Medical/Osteopathic School

commenced postgraduate training at

Name and Address of Facility

SECTION 2 To be completed by the program director of the facility for ACGME/AOA postgraduate training in the United States or Canada. on

,

.

,

and satisfactorily completed or will complete such training on

This training consisted of months of actual clinical instruction and is approved by the Accredited Council for Medical Education (ACGME), the American Osteopathic Association (AOA), or the Coordinating Council of Medical Education of the Canadian Medical Association (CCME) and consisted of the following rotations: List type and length of training. ROTATION:

LENGTH OF ROTATION:

Was this physician’s performance completely satisfactory? ●If NO, please attach an explanation.

YES

NO

I hereby declare under penalty of perjury under the laws of the State of Colorado that the above statements are true and correct and the facility is approved by the ACGME/AOA or the CCME to offer the type of level of training completed by the applicant and that the applicant was trained in an approved ACGME or CCME program position. Program Director Address Phone Number

Date

Signature

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions

CERTIFICATE OF COMPLETION OF ACGME_AOA Training.pdf ...

Coordinating Council of Medical Education of the Canadian Medical Association (CCME) and consisted of the. following rotations: List type and length of training ...

159KB Sizes 2 Downloads 149 Views

Recommend Documents

Certificate of Completion
May 10, 2015 - BUSN499 Senior Seminar in Business Administration on. 10th May ... Business Integration and Strategic Management .... Data Analysis Tools.

CERTIFICATE OF COMPLETION OF ACGME_AOA Training.pdf ...
There was a problem loading more pages. Whoops! There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. CERTIFICATE OF COMPLETION OF ACGME_AOA Training.pdf. CERTIFI

Certificate of Completion of Council on Podiatric Medical Education ...
Certificate of Completion of Council on Podiatric Medical Education.pdf. Certificate of Completion of Council on Podiatric Medical Education.pdf. Open. Extract.

CEO-Certificate of Completion-Building-edited.pdf
ADDRESS. Page 1 of 1. CEO-Certificate of Completion-Building-edited.pdf. CEO-Certificate of Completion-Building-edited.pdf. Open. Extract. Open with. Sign In.

Certificate of Completion - BA with HHS - SAMPLE.pdf
Tech LLC. ZaranTech LLC. Page 1 of 1. Certificate of Completion - BA with HHS - SAMPLE.pdf. Certificate of Completion - BA with HHS - SAMPLE.pdf. Open.

"certificate of posting " - discontinued
Feb 23, 2011 - Under the provisions of Rule 195 of the Indian Post Office Rules , 1933 ... kindly be brought to the notice of all concerned for strict compliance.

CERTIFICATE - Directorate of Medical Education
essential for the recovery / prevention of serious deterioration in the ... that the necessary approval of Director , Medical Service as required under the rules.

Certificate of Membership
Page 1. Date. December 1, 2006. This certifies that. Third Coast Guild, Khaini. Guild Master. U|ct~t zcimmer. Is a member in good standing of. Certificate of. Membership. 3 C.

Hearing Aid Provider - Verification of Completion of Training as an ...
HEARING AID PROVIDER ... Name of Supervisor: Telephone Number: ( ) ... business days if the apprentice leaves my supervision other than through obtaining full ... Hearing Aid Provider - Verification of Completion of Training as an.pdf.

"certificate of posting " - discontinued
Feb 23, 2011 - regarding 'Certificate of Posting' is enclosed for information and necessary action. This may kindly be ... INFORMATION TECHNOLOGY.

certificate of origin -
18-13E, GURNEY TOWER, PERSIARAN GURNEY. 10250 GEORGETOWN, PENANG, MALAYSIA. ... SOLAR CELL INV NO : 451.470 CBM EVC140301.1.

Psychologist Candidate - Certificate of Doctorate Education.pdf ...
Office of Licensing. Page 1 of 1. Psychologist Candidate - Certificate of Doctorate Education.pdf. Psychologist Candidate - Certificate of Doctorate Education.pdf.