Designation of the State of Principal Licensure This is NOT an application for licensure. Complete the form and send to the address at the bottom of this page. You may be asked to provide proof of residency. CO DR License Number:___________________________

License Expiration Date:__________

SECTION 1- LICENSEE INFORMATION Name: First:

Middle:

Last:

Suffix:

Previous Name(s): Social Security Number: * E-mail Address: (This will be the primary communication method) Mailing Address:

PO Box, Street:

This is a Home

City, State, Zip:

Business

SECTION 2 –DECLARATION OF PRIMARY STATE OF RESIDENCE “Principal State of Licensure” is defined as: (1) (2) (3) (4)

The state of primary residence for the physician, or; The state where at least 25% of the practice of medicine occurs, or; The location of the physician’s employer, or; If no state qualifies under the above, the state designated as the state of residence for the purpose of federal income tax.

Select ONE of the following methods:

(1) Colorado is my state of primary residence. Physical Address:________________________________________________________________________ City:________________________________________State:______________Zip:_____________________ (PO Boxes are not accepted) 

Please include a copy of your Colorado state driver’s license.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 www.dora.colorado.gov/professions

(2) Colorado is the state where at least 25% of the practice of medicine occurs: 

Please complete the table below for a minimum of 12 months.

MONTH/YEAR

NAME OF LOCATION

TOTAL NUMBER OF DAYS WORKED IN MONTH

TOTAL NUMBER OF DAYS WORKED IN COLORADO

TOTAL:

TOTAL:

(3) Colorado is the location of my employer: Name of Employer:_______________________________________________________________________ Physical Address:________________________________________________________________________ City:________________________________________State:______________Zip:_____________________ (PO Boxes are not accepted)

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 www.dora.colorado.gov/professions

(4) Colorado is the state designated for purposes of federal income tax:

I, _______________________ (print name), declare that no state qualifies under method (1), (2), and (3) as described on this form and 24-60-3602, Section 4(a), C.R.S., as a state of principal licensure and that Colorado is my state of primary residence for the purposes of Federal income tax.

ATTESTATION I state under penalty of perjury in the second degree, as defined in 18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge. In accordance with 18-8-501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute violation of the practice act.

Applicant Signature

Date

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 www.dora.colorado.gov/professions