Identification

You are applying for the Rotator PIT Permit

• Did you enter the correct license type? In order to ensure accurate and efficient processing of your permit application, you must have selected the appropriate license type.
• Initial PIT Permit - select only if this is your first application for a PIT permit in Texas (unless you are a rotator) or if you previously held a PIT permit and the permit expired or was terminated.
• Rotator PIT Permit - select only if you are a visiting resident from a program in another state. Rotator permits are limited to the dates of the rotation in Texas; however, you can reapply online for a different rotation later, if needed.
• Institution Change PIT Permit - select only if you have a current PIT permit and are now transferring to a new institution for a new residency program. You do not need this permit if you are changing departments within the same institution. Your program just needs to inform TMB of the change.

If you did select the wrong type, close this application and enter again, selecting the correct license type.

Thank you for your interest in applying for a Physician in Training (PIT) Permit with the Texas Medical Board. As you complete your application for online submission, the Board wants to make you aware of a few facts regarding criminal conduct, convictions, and disciplinary actions in other states.

The mission of the Texas Medical Board is to protect and enhance the public's safety, health and welfare by establishing and maintaining standards of excellence used in regulating the practice of medicine and ensuring quality health care for the citizens of Texas through licensure, discipline and education. One way the Board protects the public is by issuing physician in training permits to fully qualified, competent and ethical applicants.

During the licensing process the Board will ask whether you have ever been investigated by any state, arrested, charged, convicted or pled guilty to a crime. An arrest, subsequent criminal conviction, placement on deferred adjudication/prosecution, or disciplinary action is not an automatic disqualification from licensure. Instead, the Board will look at the facts surrounding the criminal conduct and disciplinary action to determine whether you are fit for licensure. You should know that licensure is a privilege, not a right. One thing you must do to obtain the privilege is to be completely honest on your licensure application.

Be sure to list all relevant complaints, disciplinary actions, charges, or convictions in response to the licensure questions. Failure to disclose such events could constitute grounds alone for imposition of fines or placement of limitations on your PIT, or even the denial of your application, or revocation of your PIT. Avoid some of the common excuses the Board has heard from people who fail to disclose, such as:

• My attorney told me I didn't have to disclose the criminal conduct or disciplinary actions.
• I didn't think the prior conduct had anything to do with the profession.
• I didn't think the disciplinary action, arrest, charges, or conviction was still on my record.
• I didn't think it was subject to disclosure because I received a deferred sentence/judgment.

Remember, there is no excuse not to disclose relevant complaints, disciplinary actions, charges, or convictions. Even after issuance of a physician in training permit, you are still required to report to the Board about subsequent convictions and disciplinary actions in other states, as they must be reported on your physician profile.

The Board queries several criminal and national disciplinary databases. This allows the Board to verify the truthfulness of your application and track subsequent criminal and disciplinary conduct after initial issuance of a permit. Keep in mind, you will not necessarily be denied a permit or be subject to an action if you have been disciplined, arrested, charged or convicted, but action will most likely be taken on your application or permit if you fail to disclose it.

Full Disclosure: It is imperative that you honestly and fully answer all questions, regardless of whether you believe the information requested is relevant. If you are unsure of your response to a particular question, answer "Yes" and submit the appropriate form if required. Your responses on your application are evaluated as evidence of your candor and honesty. An honest "Yes" answer to a question on your application is not definitive as to the Board's assessment of your present professional character and fitness, but a dishonest "No" answer is evidence of a lack of candor and honesty, which may be definitive on the character and fitness issue. Please be advised that a false response to any of these questions may be grounds for denial of a permit and reported to the appropriate data banks.

You must enter your full legal name, as you wish it to appear on your permit. Your name on this application must also match the name submitted by your Director of Medical Education to ensure timely processing of your application.

Full Name as you wish it to appear on your receipt.(required)
Applicant First Name(required)
Applicant Middle Name
Applicant Last Name(required)
Suffix	JUNIOR SENIOR II III IV V
Degree Awarded(required)	MD DO
Use this school code list to locate the code for your medical school. Copy your code from the list and paste it into your application below. If you are unable to locate your code, please use the code for an unassigned school, and be aware that this will delay the processing of your application.
Medical School Code(required)
Date Degree was Awarded (YYYY)(required)
Alternate Names
Date of Birth (MM/DD/YYYY)(required)
Please provide if a number has been issued.
U.S. Social Security Number (###-##-#### or #########)
Required for international medical school graduates.
ECFMG Certification Number
Email Address (xx@xx.xxx) Note: If you do not provide an email address, your initial information will be sent to the mailing address submitted with this application.
Gender(required) Male Female
Race(required)	White Black or African American American Indian or Alaska Native Asian Native Hawaiian/Pacific Islander Other
Are you of Hispanic Origin?(required) Yes No
Country of Birth(required)	UNITED STATES AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO (BRAZZAVILLE) CONGO (KINSHASA) COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTH TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD MCDONALD ISLANDS HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA (PEOPLES REPUBLIC) KOREA (REPUBLIC OF) KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTH MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA ST PIERRE AND MIQUELON ST VINCENT GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA S GEORGIA AND S SANDWICH SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM US MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VATICAN CITY STATE VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE
If you were born in the United States, please select your state of birth.
US State of Birth	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
The TMB personal ID Number is the number provided by your Director of Medical Education (DME). Please verify that this number is entered correctly. An incorrect entry will delay your application.
TMB personal ID Number(required)
The program number is provided by your Graduate Medical Education Office, Program Director, or Director of Medical Education. Please verify that this number is entered correctly. An incorrect entry will delay your application.
ACGME, AOA, or TMB Program ID Number (###-##-##-###) or (###-##-##-##)(required)