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Form 5 - Application for a Limited Permit

  • Section I: If you are applying for a limited permit, complete this section before having your prospective supervising physician* complete Section II. Be sure to sign and date item 9.
  • Section II: Have your supervising physician complete Section II.

Return the completed form with the $105 fee to the Office of the Professions at the address at the end of the form.

*The prospective supervising physician must be a licensed physician practicing anatomic pathology.