Athletic Commission Physician Application

Physician Form

Welcome to the online payment system for the Kansas Athletic Commission. This form is for physicians.

 

License Type
 
Name and Address Information
Required Field
Required Field
Required Field
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Contact Information
Required Field example: 555-555-5555
example: 555-555-5555
Required Field
Additional Information

Are you licensed as an M.D. or D.O. in Kansas?

 
 
Additional Information

Please fill in the following information.

Required Field
Required Field
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Physician Disclaimer

I certify (or declare), under penalty of perjury, that I have read the foregoing application for license, that all answers given are my own and that all answers are true of my knowledge. Further, I understand and agree that any misstatement of a material fact in this application will constitute grounds for revoking this license.

 
Legal Disclaimer

I hereby certify and attest that all of the information provided herein is true and accurate. I acknowledge the right of the Kansas Athletic Commission to verify this information and take appropriate legal action if such information is deemed false or misleading.

 
Payment Information
Payment Information
Required Field required