An application for a special faculty permit shall be made on a form prescribed by the board and shall include any information that the board may prescribe to establish an applicant’s eligibility for a permit. This information shall include, but is not limited to, the following:

(a) A statement from the dean of the medical school or dean or chief medical officer at an academic medical center at which the applicant will be employed describing the applicant’s qualifications and justifying the dean’s or chief medical officer’s determination that the applicant satisfies the requirements of paragraph (1) of subdivision (a) of Section 2168.1.

(b) A statement by the dean of the medical school or dean or chief medical officer of the academic medical center listing every affiliated institution in which the applicant will be providing instruction as part of the medical school’s or academic medical center’s educational program and justifying any clinical activities at each of the institutions listed by the dean or chief medical officer.

(Amended by Stats. 2020, Ch. 280, Sec. 5. (AB 2273) Effective January 1, 2021.)