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/document/form-b-pa-additional-duties-request-formpdf-0/download&sa=U&ved=2ahUKEwjctq35jJmHAxWdg_0HHaSgBiI4UBAWegQIBRAB&usg=AOvVaw33WqA70TCRxd5E08JMHs4x&fexp=72519171,72519168