SOM Alumni Signature Request Form

SOM Alumni Signature Request Form

Please submit this form if you need documentation signed.
Before proceeding to the form, please be advised that due to the influx of licensing and other requests received from Doctor of Osteopathic Medicince graduates and students during this time of the year, processing times can take 7-10 business days (two weeks).

We appreciate your patience and understanding as all the needed offices are working as hard as possible to support all our DO graduates and students.

Name

First NameLast Name
UIW Email
example@example.com
(Current OMS IV Student) UIW ID Number
Status with UIWSOM
Personal Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
UIW ID Number (PIDM), if available
Although not mandatory, providing this number can assist in reducing the processing time required for your request.
I graduated from UIWSOM's Doctor of Osteopathic Medicine program with the Class of blanks* . (example: 2021)
Type of Form

Other
Please upload the file. (Be sure that all applicant information is entered before submitting to prevent processing delays):

Cancelof
If needed, please provide special processing instructions.
**Identity Verification:** This live photo will assist us in verifying your identity by comparing it to the information we have on file. Ensure this is a live photo to avoid delays in processing
I confirm that I am a graduate of, or current OMS IV student pending graduation from, the University of the Incarnate Word’s Doctor of Osteopathic Medicine program. By submitting this request, I am authorizing the University of the Incarnate Word to disclose the requested information to the individuals and organizations listed on the documentation I have attached to this request.
Should be Empty: