Filled attestation form sample 2026

1. Click ‘Get Form’ to open the filled attestation form sample in the editor.
2. Begin by entering your name as it appears on your license in the designated field. Ensure accuracy for proper identification.
3. Fill in your home address, including city, state, and zip code. This information is crucial for correspondence.
4. Provide your contact numbers: home phone, office phone (with extension), and cell phone or pager. This ensures that you can be reached easily.
5. Enter your email address for electronic communication regarding your application.
6. Select the appropriate Maryland Board Certification option that applies to you, ensuring you check all relevant boxes.
7. Complete the practice site/location section with accurate details about where you will be collaborating with a physician.
8. List the name and Maryland license number of the physician you will collaborate with. Only one physician's information is required.
9. Finally, type your name again in the declaration section, sign where indicated, and date your signature to affirm the truthfulness of your submission.

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