History of Disciplinary Action. I represent that I have never (i) received any revocation or denial of my health professional license by a health institution or licensing board, (ii) received any complaints, investigations or charges previously or currently brought against me by a medical licensing or disciplinary board, (iii) had a plea of guilty, nolo contendere, conviction, or receipt of probation before judgment of any criminal act (excluding traffic violations) and/or act involving dangerous controlled substances or alcohol, (iv) violated U.S. laws and/or Executive Orders prohibiting provision of resources and support to individuals and organizations associated with terrorism and terrorist-related activities (including never having my name listed on the Specially Designated Nationals List published by the U.S. Treasury’s Office of Foreign Asset Control (OFAC). I represent that I do not illegally use drugs.
