Shem » Ss The Davey oe Salt New Yo Deparment Oty Medicine Form 1 {THE STATE EDUCATION DEPARTMENT Ohce ce tess Pema it an Ce RE ition PROFESSIONAL LICENS Ree tern Aecrue ee ‘Nang. mY 12258-1000 DN 2S ATTY “wcnoysesaee Sas Application for Licensure and First Registration 0 fe) Ge 1 | Seca Security Number Die sued Applicants Must Complete All Six Pages Of This Application Im ink [ws canes mumbor) 77/7 ne) ie 3 2] orm one von fll RT ¢ eS 3] Pein Name Enact As You Wen io Appear On Your Lene 3 ie ws (le ToTeln Tal al-Imlols Tels 1 | } osaenore us Blalelalalal | LITT TTT af DI lolallsT> al weoe EJ] i Islet 1) 11 TIT T ] Tes Gea Peone te wating ateress (rou ret rey te Deparman prone any adress mame changer) aa Asien Pena pi ce) roves DlelPla le Het el alt Tol el Toll -lelx lai [medonr g3@ med.nyv.eds swe Fle] [File [s[tl Aviles J (et ow (Welt T7To Le H ] sare [Wy zpcece [110101 116) rowers CI TI i ] oe at posure on aren so ateenttonsvor) Racgac 4 basal) 7] capone: on Aen lowaly admited or 8 permanent gesidence in re United Siates cutzanot Stach 0 oe er ee er yon Aten eration Card Tesh wo enor lcanaed 90 Bw Basle EB Acceptabrenamsnt scores (500 page Bo! Ps fom) 1D Endorsement otanother teense (See Aopisanis Lansedin Another Stab" scten onsite amusing FOVS wcatectmy erecentais OQ ves Ono B | ave you revously apnea fora New Yor Sire conse o ted peo price mestine? , Des tno 0) wre you ever boon ound guy ora 6” plenare polly no eEnest nto coenéere tow hme (elony ot a tho ‘ernest 71] fre comin charger posding apart you In any coun? v ms i 712] as ony casing on iscainary abort refused w stv yous Hoong o era revoke, annul creas, sceepes ter ict susbensed pines on probavan,relureatoenew a prafessral cerst 0! crete hel by you now oF ves fo Froiousy e over Foe eonurea reprimanded a eerie Guctnes yO? [73] ae charges porcing aparl you nny aie fa ony eo of proleatana mieconauc? vo eo Fa] tos any rospia' or uceraesfaciyveaticieg cr eminted you pressions sing, employer. Bivieges va Bn test ou ever olutely er meus resigned orawn fm such arvouslon avoid poston NOTED H you anewor Ver" any questions numbered 10-14, subi eter giving complete explanation. Include cases of ary More: tae ardiyou possess ona, a copy olihe Certcaleof Rebel fom Disabiies” or yout “Cerifeate of Good Conduct” Tedicne Form 1, Page tel, Septerber 2008jnaanguane ond Ge ATENOANCE EeNo DLN pe ocekce gente monce cof enone EARNED - a em se | a enedtine, vo eles So wy eh as ee as Z ach dona! shoes neces iets inet erthins 9 country eer han where your medial choos lected ie the dates an cation et nese ce tame of Heats Care Fao ‘asia Seno wi wich ‘mcive Cterhshp Oates Giniat Ate ‘ara Rdaeas ‘lerksigAfuateg and AaoressTe] ire you wensed orhve you ever Been loenseG a epyskian nen) oer sate e county? va te tyes, fat each usscton. appropriate, you mut lso submit 8 Fom 34 of 38.8 papes M18 ~ Basis of License site or te License County Issues ny iatons rulcensa umber | “Eaminaton Bareoter | eneorsement | Other 17] complete tin section only you ave a graduate ofa prograre na eletered by New York State or CME or ADA accredited, Have you complete al gortons ofthe examinasonequremenis or ECFMG centeaton? = C] ves) wo ‘Do you curenty nals asd ECFIAG certificate? DO ves O no reose complete and forward the EGFUG form. 8] Ao yousppirng for vanauie on te bass 2 Fith Patna proren? Dw Ww ives. st name ad ocatlon ef racial schoo! or resi ae the dus ales of atendace Tame wd Location ot eieat Soar Hospi Trcuave Dates tendance fis] Latin Engin, at epesaty auatieatons you have ened (@., Bosd Specialy Centeaton or Diplomate Gentcet) 1c Quaieatons ‘Nar and oes of organaation suing eezenal 2} 7) swrbeapping fer USHLE step 3 on JE ne cea oan ramen orion nce ow ) roub aunurvoncomanarions FLEX Patel. on LUSMLE Slepe 1 and? ond NSWME Pati FLEX Components aa LUSMLE Step 1.NBME Part and FLEX Component NOME Pan and NOME Pact, USWLE Step 2, ans FLEX Component NOME Pont land 298 USKLE Sip 3 USHLE Steps 1 and 2 ond FLEX Comore NOME Pant, USMLE Step 2 and NBME Pert NOME Pare and ee FLEX Componet NBME Pont ane USMLE Steps 2 and 3 FLEX Component | and USWLE Sieg 3 ooo0o000g0 ooooooo00 ust AOE Poss an Step 1 on NBME Pots a i ciner — 7, sonennononseconcavarcmsnne 917 / 2006 ‘Wedicne Form 1, Page 3 of 6 September 2002 __Jrove a chvorciageal tot) aztes shoe graduation om potesinsl schoo! tothe present, include vacation pegs a pevods of lenporment. Atoch adional shaats recess ATE jrrea “ype of actviy, Bering with Oat of Graduation fom Protessont Sctoe Inde Name ana Across of Employers Tilo | Peer |New Yorks voivesiky Seber! of Med eine Rsideocy 1 ttetebics end tbynecslege sso th Ave, News Yor, WY 10016 . BIZ-263- cea : 22 \1you hola New York Sal zane in anther pots, nate he prleton youreense umber ane gate of Nensure be, Pression (Geeren Number ‘Date of nal Licenewe ty ha 2 CHILO ABUSE IDENTIFCATION AND REPORTING: (check enly one of the flowing) t | graduated trom a medical school in New York State afer September 1.1890, “sem haces ton ase senate tmanserone ae Ft omtiing for an exemption i ne vequieinent ard have encloses the exemption for. tam going totake the Chis Amuse wienttcation course and submit the eaqured form, THediene Fev 1 Page 4 of 6, Seplember 2008 |GENDER AND ETHNICITY: (Thi Information on gender and ethnic Is sought slay tallow the Edueaton Department to eatect and analy deta conceming givers in the feensed professions. The elhnie and gender dla you provide willbe used only or stlisial, research, end preyam waliton ‘purposes i wilino be sabes tothe pubic. Thisnformation has sbrluey no Beri on your avaliletion for ieentore Ecc: AP nln vrnasec) Roses QM scpaie IP soe sewcn ite s optional) 2 STUDENT LOAN DISCLOSURE! The State Eeucston Depsrmert is requitc” to ask ese quesions about aay suet ans made or quaranots ty tha New Yok Soe Higher Evealn Series Corperaon art fosvare ary 'yes" respons tate New Yor ita ger Euston Senses Caporsion Your hcense 2ppleaton & rot comple without ts Information (2) Do you have anyoustancing loans rave or quartet New Yo ves Ne State Higher Ecueaion Sences Coraion? j (©) styeunave sich atari is any parincetal? ves Ne “Wea You Sat Eaveaton Low, sion 6801-9 26 CCHLD SUPPORT OBLIGATION: \ Everyone agsyg oor senewing a polessons bens, er, rexstoion must he a witen sate thal, 35 ol Be ce oh fg, he sho 'Srorts nek uneer an obigaten to pay ee suppor. Induals who ar eur months er more In mete in eid suppor may be subeat te suspension of thelr Busless,prfessinal andor divers lcerses, The Hteaoal sbmasion ol aie witerstaemeris he purone ot frosting or deeaing te aut evosceen! of supper obigatons ponsatie uncer sacion 17535 lhe Penal bw You must complete tis section fore we cc ese Le cede Ix wich you have applad. ngksduals who we notin capac wih te ceagaton to p2y eta pp canbe esue aeedenallorna mate han ah month nro comply wh Ser hid suppor abso. Check only &oFB below. Hfyou check B. you most check one f the five statement es bolo ar not unr an obiatin to pay cid supe: on am uncer ancblgaton te pay 2d nicpon a pina check oni one of he flowing) am eater ane am ot aur monn of more Mae ne pret ech spot oF, gm mating payments by come excoson r by cout ogee pyment pone by & plan agreed o Uy fe pari: The cd suppor abigalen isthe autet a2 peding cai proceeding, am eceng peti assistance or supplement secnlyncore ‘None lhe above oe eatments ae “Wew York Sate General Osignton Law secion 3.503, luedicine Form 4, Page & of 6 September 20021 give permission to the New York State Education Depariment io release my examination results fo my prcessional schoo! for the confidential purposes of program review and insitulion research and planning | may rescind this authority at any time by notifying the Division of Professional Licensing Services in inting YB ves, Cno preateinsar Rem 28 PHOTOGRAPH REQUIREMENT: | [28] AFFIDAVIT WITH ACKNOWLEDGMENT (rswrzsten weauves) APPLICANT { ceciare and afm thet the statements made in this application, including accompanying documents, are rue, complete and correct, | understand that any false or misleading information in, or in connection with, my application may be cause for denial or ass of licensure and may resuil in erminal prosecution, Sijnatre of the appcant igen Gh fnmmny ores . NOTARY State of Ase Ye cl: Countyot__Q@yr ent one _# a, ihe yeor_JeeD\belore mo, he undersigned paseraly appeared Jd mjon Ye “Pasonalytronn oe cr ofved foe on the bass cf sasitay evence ei ne ES tate wece HEGEL Bao ve mpeton sn stvowncped tome ha ete eee he application ard swore tha te slaoments made by hinvher inthe application and all supporting mateals re tue. comple, and corect Z Notary Pub signature Notary IDnumber A/¢ USOF{L2Z 2 \ JO-ANN A. CHTRORE: norers Rubia Sate of New York fsposeusoaia22 ices gueens Gout conmanvntapnecmarnat, ZOU Expiration date (og 1 ae. Section, Division of iz form and approprisie fen (o: Now York Slate Education Department, Ofice of the Professions, F Professional Liconsing Services, 69 Washington Avenue, Albany, NY 12734-1000, DO NOT SEND CASH. Make check or money ‘order payablo to the New York Education Depariment. Mocicine Form }, Page 6 of 6, Sepleribo 2008ficate hnps:lwww.nursesleaming com/coursesteer-122-CA.cfm?CoursekKe, NI Certificate of Completion ‘This certines that Raegan McDonald-Mosley, License: NY , has successfully completed an approved course on April 30, 2007 in Child Abuse and Maltreatment/Neglect: Identification and Reporting New York State Mandatory Course as mandated by ‘Chapter 544 of the Laws of 1988. . ‘This program wae presented by the Preventing Child Abuse Network ‘Now York State Provider Identification: 80869, 12766 South Arlington Mill Drive - Suite 215 ‘Arlington, VA 22206 Margaret M. Cotroneo PhD, RN CS. (Signature of certifying officer) Approved by the New York State Education Department Contact Hours: 2.00 Date: 4/30/07 ‘Location: Remote tof an 2007 12:47 AMty 1 S7/E007 98,96 FR etzHD 10280 CANON ; ™, 002/009 : eon [Form 2 “The Ue Pe Sail Now York i We | . ‘me aTateebuension seewtuet “6 & MEDICINE ‘ea cline Pes ee bs, Sits etn etn one 7, % | sone 4% | CERTIFICATION OF PROFESSIONAL AND PREPROFESSIONAL EDUCATIGR “APPLICANT NSTRUCTIONS ofr ieatia a (Mita tee. Heal ix eoathaai riafe Ove eo 1” Comeiele Sesion Ere yourrare 38 appears yeu New Yon Sala League Appicaen (Frm 1) or imied Parl Appleaon arr SEP3s eve ta van and ses tem 10 2. Seng tis farm he prtersional tool you manded te compels Sect I, Be gure to Ince any fae raguend you padvate’ ow @ ena) Ita ane us scoreany Ne 3 sfyou stanoed a meta sche! Oat 700 (2 9. SEESCYT 4 Tha lommust be ned by the Regie. Oven Reco or Pritepa of he madleal scat ana san! bac dec eine Oice ae Profesties | Fy hot tol ental anol eenclenvecha se easensaine ena this form Pore aan sac bythe eppeeen ore! pees wii | Porn acepes ‘SECTION: APPLICANT INFORMATION [3 soca secunry nacre Sa -SaR, 7] orm oare leesnion bark iy oe na Soe! Sey ew Tien D4y eee PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1) (OR LIMITED PERMIT APPLICATION (FORM 56) un (le ToT Tn Ta Td = LeTye Tt 1 EE] wencenonere ae vw (Rlalelglala T 1 HOME swe ET TT i]s Tet “TL T Thi WALING ADDRESS: Bren coor Numba? work soutien (aliizHaleHiisiek) “es Code Nimo! | ow (ile [ut Tyfe Ir TR LL TL] tabaci mediayuctl! om WE Pius Asece foto. T I Li Con 18] piriname uncer wicn your deve or lems wn award ve tm aba Jaga MOgaald- ot Prepeterina Soot Aten [i] Priosene stewatedet Univ Meine Asonse [5] wmeesoereovens ache A Adinine omen S/e00 [10] request an give my perenne acroe hed i ta 8 bore La comslata Seton of fr an setoereecensece | Dap ate ectesa a te onthe fo, anal rleae ey abr Ploaton faauaw'ed by the Siae Baas Deparerk 9 comet peaeaeers ronan SEO IRR an FS BaD ‘Spier aE ‘CERTIFICATION GY PROFESSIONAL SCHOOL OFFICIALS TO WEWADE ON NEXT PAGE FORWZ,PAGEVOF®06/22/2007 08.96 FAX 2128910290 canon Bo03y002 SECTION Il: CERTIFICATION OF PROFESSIONAL EDUCATION ISTRUCTION TO SCHOOL: Pheste compl is sttlon, tp entyng esomon, achihe lomaionreauhed tm 3 nd and racy 2 Iho Otis ofr Poteaonrat th bocrese snow talow. Tis frm wot Be secepla i rornaa by te epplcen es othe! per. For Anpionts rom N.S. Registered or LOME/AOA Accredited Mado! Scoot: ‘Aplean! met LEMEIAOA requemants fr samittontomucealonsopenicecheo? ves Ono Ittio, med! rpreesioal postesondany ered hare compl’ by npacon perl efmationto madi ehoe? teoanarhoun | got Fou 2) i te epstnrarecove avanes tuncing Beaton pr wade won? Ovs Bo Fea edewe wire ponents conned ceed eer tno wane ves your ala, 06 cpt {dvcanaion yo ha eopunegrvege! Pee Ore. a 2) scoteancsrvance te: 21 AL 1 1999 ceonamenone: S117 1004 4) onreeeooma cient 10.D./ Doctor of Medicine ooesroonmt F117 1Q004 vest atencance 5} rerav omer Applicant: ‘Year fedveaton aut r dmiston a your medi eco Preseeesons crecentavgreeeutrntin by pte or ation ja made! ecnok Wes Seca Sertceecuins? C1 ves C1NO Yes, cholncuatocutes and ane ol inttsen which equiemes wat met Inston aw 'e Wace pegradusioniniemsnip eaves? C) ves C2NO 11Yae.ghe behav ente and nan cineinson a wnchrquemen Inns, ate w. ‘A. Anche worst (course recedes staheets)ehowng cures ten st yer nstaion ‘na ccapieg trom ober tnd fr ae of crn 1 conmiceion The wanesrpt must bear te orga signature of te roplcir, geen prnelsl or rector and orginal sloth echo. 18, Acaoy ot Institution News Hace Wnivtsief Scheel_af Medicine (SEAL) noses 950 FIG Aven | Nett a dow ‘weptone 207 = 20°9- YEE roe 212-263-9251 emolasiers Swi sayin @ ned oyucde Return thie form rectly Now York Stele Edveaton Deparment, Otice o! Uns Prolssion, Disko of Pro — { Services. Medicine Llownsn Un 89 Washingln Avenue, Abany, RY 12234-1000 FORWZPGT, PAGE DOF? ‘September 2002