KSTAR Fitness for Duty Evaluation Application

Page 1 of 5 - Applicant Information

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Full Name Full Name * First Last
Email *
Phone Phone * - ### - ### ####
Home Address Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Gender *
Date of Birth Date of Birth * / MM / DD YYYY
Degree *

Degree MD DO DPM Other
Specialty of current clinical practice: *
Are you currently in practice? *

Are you currently in practice? Yes No
If not, how long have you been out of practice? *
List all states in which you are licensed to practice medicine and your license number (ex. State, License Number, DEA Number): *