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/document/form-b-request-additional-duties/download&sa=U&ved=2ahUKEwjF4cr3vJeHAxVF2wIHHYWSBeo4HhAWegQIBRAB&usg=AOvVaw1kVzDN64jrP0793zWot-9b&fexp=72519171,72519168