CERTIFICATE OF MEDICAL EDUCATION SECTION 1 To be completed by applicant and forwarded to school where medical degree was received. This certifies that
Full Name of Applicant
enrolled in
Full Name of School
_______________________________________on the ________ day of Location of School
Day
,
Month
Year
SECTION 2 To be completed by president / secretary / dean of medical school and forwarded to the Office of Licensing. The undersigned certifies that the records of this institution show that s/he attended this institution beginning on the
Day
day of
,
Month
Bachelor/Doctor of Medicine or Doctor of Osteopathy on the
Year
Day
day of
and was granted the degree
Month
__ , ___________
Signed and the college seal affixed This
By
Day
President
day of
/
Secretary
Month
/
,
Year
.
Dean
NOT VALID WITHOUT SCHOOL SEAL NOTE TO REGISTRAR: If no school seal, please indicate above next to signature of President/Secretary/Dean.
1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800
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