This government document is issued by Composite Medical Board for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/Files/FormC1PhysReinstateStateVerif.pdf&sa=U&ved=2ahUKEwjctq35jJmHAxWdg_0HHaSgBiI4UBAWegQIAhAB&usg=AOvVaw2VLlH425qjRaNZrznZlj4X&fexp=72519171,72519168