Homeopathy: Residency Verification

Public Health: Verification Of Medical Residency Training

DPH Data Management and Governance (PLIS)
APPLICANT: Enter your full name and birth date on this form and forward it to the Chief of Staff or program director at the facility in which you completed your residency training. This form must be completed by the facility and returned directly to this office.
Applicant’s Name:

First NameLast Name
Date of Birth:

MonthDayYear
Dear Chief of Staff/Program Director:

Please provide the following verification of residency training for the above-named Connecticut physician licensure applicant
Name of facility where residency training was completed:
Dates of Residency: From

MonthDayYear
To:

MonthDayYear
In what specialty was the residency training completed:
At what level(s) was this residency completed (PGY1, PGY2, etc.)?
At the time of the applicant’s training, was the residency training program in this specialty area accredited by the Accreditation Council for Graduate Medical Education?
Did the applicant satisfactorily complete this period of residency training?
Do you have any derogatory information regarding the competency or conduct of this applicant?
If yes, please attach any disclosable documents you may have on file regarding such information
I, First Name Last Name being duly sworn, do depose and certify that I am the Chief of Staff /Program Director at:
Name of Facility:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
And that the information provided herein is true and correct to the best of my knowledge and belief.
Signature of Chief of Staff/Program Director:
Subscribed and sworn to me this Day day of month (month/ year) year
Notary Public’s Signature:
My Commission Expires:

MonthDayYear
Please return this form directly to:
Department of Public Health
Homeopathic Physician Licensure
410 Capitol Ave., MS # 12 APP
P.O. Box 340308
Hartford, CT 06134-0308
Should be Empty:

Public Health: Verification Of Medical Residency Training

Dear Chief of Staff/Program Director: