653—9.5 (147,148,150,150A) Permanent licensure application.
	 9.5(1) Requirements. To apply for permanent licensure an applicant shall:
	  a.   	 Pay a nonrefundable initial application fee of $450 plus the fee identified in 653—subrule 8.4(7) for the evaluation of the fingerprint packet and the criminal history background checks by the Iowa division of criminal investigation (DCI) and the Federal Bureau of Investigation (FBI); and
	  b.   	 Complete and submit forms provided by the board, including required credentials, documents, a completed fingerprint packet, and a sworn statement by the applicant attesting to the truth of all information provided by the applicant. A completed fingerprint packet is not required if the applicant has held active physician licensure in Iowa within 12 months of applying for permanent licensure and fingerprinting was done prior to the issuance of that license.
	 9.5(2) Application. The application shall require the following information:
	  a.   	 Name, date and place of birth, home address, mailing address and principal business address.
	  b.   	 A photograph of the applicant suitable for positive identification.
	  c.   	 A statement listing every jurisdiction in which the applicant is or has been authorized to practice, including license numbers and dates of issuance.
	  d.   	 A chronology accounting for all time periods from the date the applicant entered medical school to the date of the application.
	  e.   	 A certified statement of scores on any examination required in rule 9.4(147,148,150,150A) that the applicant has taken in any jurisdiction. An official FCVS Physician Information Profile that supplies this information for the applicant is a suitable alternative.
	  f.   	 A photocopy of the applicant’s medical degree issued by an educational institution.
	 (1) 	 A complete translation of any diploma not written in English shall be submitted. An official transcript, written in English and received directly from the school, showing graduation from medical school is a suitable alternative.
	 (2) 	 An official FCVS Physician Information Profile that supplies this information for the applicant is a suitable alternative.
	 (3) 	 If a copy of the medical degree cannot be provided because of extraordinary circumstances, the board may accept other reliable evidence that the applicant obtained a medical degree from a specific educational institution.
	  g.   	 A sworn statement from an official of the educational institution certifying the date the applicant received the medical degree and acknowledging what, if any, derogatory comments exist in the institution’s record about the applicant. If a sworn statement from an official of the educational institution cannot be provided because of extraordinary circumstances, the board may accept other reliable evidence that the applicant obtained a medical degree from a specific educational institution.
	  h.   	 An official transcript, or its equivalent, received directly from the school for every medical school attended. A complete translation of any transcript not written in English shall be submitted. An official FCVS Physician Information Profile that supplies this information for the applicant is a suitable alternative.
	  i.   	 If the educational institution awarding the applicant the degree has not been approved by the board, the applicant shall provide a valid ECFMG certificate or evidence of successful completion of a fifth pathway program in accordance with criteria established by AMA. An official FCVS Physician Information Profile that supplies this information for the applicant is a suitable alternative.
	  j.   	 Documentation of successful completion of resident training approved by the board as specified in paragraph 9.3(1)“d.” An official FCVS Physician Information Profile that supplies this information for the applicant is a suitable alternative.
	  k.   	 Verification of an applicant’s hospital and clinical staff privileges and other professional experience for the past five years.
	  l.   	 A statement disclosing and explaining any informal or nonpublic actions, warnings issued, investigations conducted, or disciplinary actions taken, whether by voluntary agreement or formal action, by a medical or professional regulatory authority, an educational institution, training or research program, or health facility in any jurisdiction.
	  m.   	 A statement of the applicant’s physical and mental health, including full disclosure and a written explanation of any dysfunction or impairment which may affect the ability of the applicant to engage in practice and provide patients with safe and healthful care.
	  n.   	 A statement disclosing and explaining the applicant’s involvement in civil litigation related to practice in any jurisdiction. Copies of the legal documents may be requested if needed during the review process.
	  o.   	 A statement disclosing and explaining any charge of a misdemeanor or felony involving the applicant filed in any jurisdiction, whether or not any appeal or other proceeding is pending to have the conviction or plea set aside.
	  p.   	 A completed fingerprint packet to facilitate a national criminal history background check. The fee for the evaluation of the fingerprint packet and the DCI and FBI criminal history background checks will be assessed to the applicant.