University of Washington School of Medicine

August 26, 2015

Faculty Name (s)

Title (s)

Department (s)

University of Washington School of Medicine

Box number

Seattle, WA Zip

Dear Dr. Name:

I understand that you have an upcoming visit to hospital or institution name, during which you will be performing services from dates.

I understand that the University of Washington (UW) requires certification by the host institution that local licensing, if necessary, of medical professionals has been acquired for the duration of the visit. Accordingly, the purpose of this letter is to confirm and certify the following:

· you do not need local medical licensure for this activity

· you will not be out of compliance with local licensing laws by engaging in the planned activity.

The relevant law validating these assertions can be found at location.

Please let me know if you have any other questions.

Sincerely,

Department/Ministry of Health official

Title