Homeopathy: License Application
  • Public Health: Homeopathic Physician Application

    Public Health: Homeopathic Physician Application

    DPH Data Management and Governance (PLIS)
  • Please check one:*
  • Date Granted:*
     - -
  • PLEASE INDICATE (X) THE EXAMINATION(S) YOU COMPLETED:*

  • If Selected State Board Licensing Exam (Please specify state and year taken):

  • Name and Mailing Address: This will be how your name and address will appear on your official license, your address of record for all mailings from this office and releasable pursuant to Freedom of Information requests.

  • Format: (000) 000-0000.
  • Date of Birth:*
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  • RACE/ETHNIC DATA: (This section is voluntary. Information gathered will be used solely for the purpose of examining the demographics of Connecticut licensees. This data will not be used for discriminatory purposes and will not be considered in the evaluation of your application.)*

  • Medical Education:

  • Date Awarded:*
     - -

  • Medical Licensure:

  • SPECIALTY:
    If certified by a specialty board approved by the American Board of Medical  Specialties (ABMS), indicate name of American Board:

  • Date Certified:
     - -

  • Medical Practice:

  • At the exam, do you require accommodation for any disabling condition?*

  • If Yes, attach a separate written statement to the application, briefly describing the nature of your disability and the accommodation you are seeking. Upon review of your request, this office will contact you for appropriate documentation.

  • Statement Of Professional History:

    Please answer the following questions referring to the instructions, if applicable
  • 1. Have you ever been censured, disciplined, dismissed or expelled from, had admissions monitored or restricted, had privileges limited, suspended or terminated, been put on probation, or been requested to resign or withdraw from any of the following:-Any hospital, nursing home, clinic, or similar institution;-Any health maintenance organization, professional partnership, corporation, or similar health practice organization, either private or public;-Any professional school, clinical clerkship, internship, externship, preceptorship or postgraduate training program;-Any third party reimbursement program, whether governmental or private?*

  • If your answer is "yes", give full details, names, addresses, etc. on separate notarized statement.

  • 2. Have you ever had your membership in or certification by any professional society or association suspended or revoked for reasons related to professional practice?*

  • If your answer is "yes", give names of professional society or association, date and reasons your membership or certification was suspended or revoked on a separate notarized statement.

  • 3. Has any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction, limited, restricted, suspended or revoked any professional license, certificate, or registration granted to you, or imposed a fine or reprimand, or taken any other disciplinary action against you?*

  • If your answer is "yes", give full details, names, addresses, etc. on a separate notarized statement

  • 4. Have you ever, in anticipation or during the pendency of an investigation or other disciplinary proceeding, voluntarily surrendered any professional license, certificate or registration issued to you by any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction?*

  • If your answer is "yes" give full details, names, addresses, etc. on a separate notarized statement.

  • 5. Have you ever been subject to, or do you currently have pending, any complaint, investigation, charge, or disciplinary action by any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction or any disciplinary board/committee of any branch of the armed services? You need not report any complaints dismissed as without merit.*

  • If your answer is "yes" give full details, names, addresses, etc. on a separate notarized statement.

  • 6. Have you ever entered into, or do you currently have pending, a consent agreement of any kind, whether oral or written, with any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, any branch of the armed services or a foreign jurisdiction?*

  • If your answer is "yes" give full details on a separate notarized statement and submit notarized copy of agreement.

  • 7. Have you ever been found guilty or convicted as a result of an act which constitutes a felony under the laws of this state, federal law or the laws of another jurisdiction and which, if committed within this state, would have a felony under the laws of this state?*

  • If your answer is "yes" give full details on a separate notarized statement and furnish a Certified Court Copy (with court seal affixed) of the original complaint, the answer, the judgment, the settlement, and/or the disposition of the case.

  • 8. Have you ever been denied or surrendered a state or federal controlled substance registration, had it revoked or restricted in any way, or been warned, reprimanded or fined by the responsible agency?*

  • If your answer is “yes”, give full details, dates, etc., on a separate notarized statement.

  • On this * day of * ( month/ year)   *(applicant's name) personally appeared before me, who being duly sworn says that she/he is the person referred to in the foregoing application and that the photograph attached hereto is a true picture of self and that the statements made herein are true in every respect. 


  • AFFIX A RECENT PHOTOGRAPH HERE.

    DO NOT STAPLE

  • Sworn to me this * day of * (month/year)   *   

  • My Commission Expires:*
     - -

  • Please return this application, the fee for $565.00 (certified bank check or money order) and a separate certified bank check or money order for $4.75 made payable to, “Treasurer, State of Connecticut” to:

    Department of Public Health
    Homeopathic Physician Licensure
    410 Capitol Ave., MS# 12MQA
    P.O. Box 340308
    Hartford, CT 06134-0308

     

  • IMPORTANT: Please do not send this form and fee unless you have read and understood the licensing policies and requirements. All fees are nonrefundable.

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