Part 1: To be completed by the Department

  • 2111 and 2113 Initial Application Request
  • 2111 Department Letter to Request Dean’s Office Support
  • Ensure the 2111 Applicant has completed the form and provided the required supporting documents.
  • Ensure the 2111 Applicant and Department Chair sign the 2111 form.
  • Submit both the Internal Forms, 2111 Application, and required documents via email to the DGSOM Assistant Director for Visa and Licensing Office.
  • Joan Grace Cerera will return the signed Dean’s Office Support Letter and 2111 Application to the department for submission to the Medical Board of California.

Note: It is the responsibility of the Department Coordinator to submit the application and documents to the Medical Board of California and copying Joan Grace Cerera in all correspondence

Part 2: To be completed by the Applicant

  • Medical Board of California Forms
  • Return the form with the required items to the department that will be recommending you for the 2111. DO NOT send them directly to the Medical Board or the Dean’s Office.