Your residency permit application is time sensitive.  Please scroll down and download the PDF-fillable application and send via Express Mail to the residency address below (DO NOT mail to the State Medical Board).   You can use our USPS Corporate account to bill this to us: 995371-8241 

**Need original signatures on this application**

Denise Gleason | 1201 E. 36th Avenue | Anchorage, AK 99508

Below, I breakdown the application packet on pages that get additional questions and I also pre-filled sections that will be the same for everyone.  There are 21 pages total.  You can type or handwrite the application. If you make a mistake, please re-print the page, as the state will not accept areas of the application that have been struck through, corrected, and initialed. 

• Page 4

  • Please fill out your demographics and list your current residence address in that section.  I have pre-filled the box for them to use our practice address as the address on public record and they will mail your license to the residency.

  • Maiden/legal name change - include documentation of your name change/marriage certificate, etc. (it does not need to be notarized, a copy is fine)  

• Page 8

  • Under Professional Licensure (if you were previously a nurse, healthcare professional etc. you'd list that there)

• • Make sure you mark the "Yes" or "No" box in the Medical Malpractice History section.  That gets missed often.  

• Pages 9-11

  • If you answer "Yes" to any of the "Professional Fitness" questions, you must provide an explanation with the application on a separate piece of paper. 

• Page 12 | Notary Page

  • You can get passport-type picture or use the picture you used for your ERAS application.  

  • The date you sign the application and the date that the notary signs the application MUST MATCH.  Please make sure the notary also applies their seal partially on your picture as indicated on the page.  

• Page 13 | Authorization for Release of Records 

  • You will still need to fill this out even if you provided an explanation on a separate form.  

• Page 14 | Verification of Medical/Osteopathic School Education Form

  • Please work with your medical school registrar a couple days before or right after your graduation to fill this out.   This form CANNOT be dated before graduation or the state will require a new form with a new verification date and it delays the process.  

  • Due to COVID your medical school can email it to the medical board:  medicalboard@alaska.gov 

    • • **Please have them CC you when they email to the medical board**

• Page 15 & 16| Verification of Good Standing & Acceptance of Responsibility 

  • Fill out your name, DOB, and then sign at the bottom and then I'll have the program director sign their portion.  

• Page 17| Physician Board Action Data Bank Inquiry

  • Fill out the information and the Residency will mail this request form in for you.  

• Page 18 | Verification of Licensure Form 

  • Complete this form ONLY if you’ve been licensed in other states (e.g. MD/DO, PA, RN, etc.) and forward it to the appropriate state licensing boards for completion.  Touch base with Denise if this applies.

• Page 19 | Letter of Explanation for a Professional Fitness "YES" Answer 

  • You will still need to fill this out even if you provided an explanation on a separate form. 

• Page 20 | Credit Card Payment Form

• We will fill this form out for you when we submit for payment, please disregard. 

• Page 21 | Authorization to Discuss Application & Share Information 

  • This form allows me to communicate with the licensing examiner about your application, status, and if there's anything missing I'm able to communicate with them on your behalf.  

Additional Items

• Med School Diploma

  • A certified true copy of your diploma is required for your resident permit.  The notarized copy of your diploma must have the following wording:  “I certify this to be a true copy of the original document” and it needs to  be signed, dated & stamped by a notary.  

    • • **If you can get an electronic copy of your Diploma--please email it to me and I will just have it notarized.**

      • You do not need to wait for this to mail me your application since med school diplomas aren't available until a couple months down the line.  

  • Please check with your school to see when they will be sending out diplomas.  If you will not have your diploma by the second week of June, please let me know because we will need to obtain official transcripts and have them sent to the medical board in lieu of your diploma.   

  • Also please scan a copy of your diploma (it does not need to be notarized) and email it to me, as I'll need it for your personnel files

• Resident Permit Fee  

  • The Residency will cover this fee, that is why you will submit this completed packet via EXPRESS MAIL so that we can submit and make the payment.