Quarterly Declaration - California

BUSINESS, CONSUMER SERVI CES, AND HOUS I NG AGENCY - D epartment of Consumer Affairs EDMUND G. BROWN JR., Governor
M EDICAL BOARD OF CALIFORNIA
Refer to www.mbc.ca.gov for office locations
Quarterl y Decl aration
INSTRUCTIONS: Please type or print neatly. ALL requested information and questions on this form must be answered. When space
provided i s ins uf fi cie nt, att a ch addit ion al sheets of p aper . All attachme nts are con sid ered part of th e Declarati on. You ma y w ish to make
and retain a copy of the m aterial subm itted to t he Medical Board. Mail the complete d Declaration to your assigned pr obatio n monitor. DO
NOT FAX your Declaration. The Medical Board requires an original signature on each quarterly declaration and a faxed signature will
not be accepted.
Check Appropriat e Box for Reporting Period Covered
Reporting Period Due to the Board By
January - March (First Quarter) April 10
April - June (Second Quarter) July 10
July - Sept em ber (Third Quart er) Oct ober 10
October - December (Fourth Quarter) January 10
(Continued on reverse)
Name: First Middle Last Aliases
Home Address: Nu mber & Street City State Zip Phone Number
( )
Primary Place of Practi ce (i nclude additi onal plac es of practice on reverse)
Address: Number & Street City State Zip P hone Num ber
( )
E-mail Address:
Work ________________________________________________
Personal
Cell Phone Num ber
( )
Indicate the number of hours worked this quarter at your primary place of
practice:
P er week Per month
What is your work schedule at this place of prac tice?
The Following Questions Refer to t he Time Period Si nce
Your Last Quarterly De cl ar ation
1. Have you violated any count y or city ordinances, been arrested, charged, convicted of, pled nolo
cont endere in any state or federal court or foreign count ry to any misdemeanor, f el ony, or other offense?
(If yes, specify which one in your explanation. E xclude parking tickets.)
2. Have you violated, been arrest ed, convicted of, or received a citation for driving under the influence of
alcohol or drugs, reckless driving, or any ot her vehicle code violation involving alc ohol or drugs?
3. Are you required to undergo biological fluid testing by any directive other than what is in your
Order? If yes, when were you last tested and what is the frequenc y of testing?
4. Is there any governmental, civil suit, malpractice, or peer review pr oceeding pending against
you?
5. Have you resigned from any employment or has your em pl oym ent been terminated?
6. Are you in the process of applying for any other business or profess i onal licens e or
certificate?
7. Have you had to report any theft or loss of controlled substances to the Department of
Justice?
8. Have you had to report a patient death in an outpatient surgery setting pursuant to Business
and Profess i ons Code secti on 2240(a)?
9. Did you cease practici ng since your last report? If yes, give t he date you ceased practice.
Yes* No
Yes* No
Yes* No
Yes* No
Yes* No
Yes* No
Yes* No
Yes* No
Yes* No
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