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Application for Associated Health Occupations


Application for Associated Health Occupations
Application for Associated Health Occupations
8. SOCIAL SECURITY NUMBER
3. APPLICATION FOR (Check one)
16A. NAME THE CERTIFYING BODY
FOR YOUR HEALTH OCCUPATION
16B. DATE OF MOST RECENT
REGISTRATION/ CERTIFICATION (Give
Month and Year)
14C. CURRENT REGISTRATION
(If "NO" explain on separate sheet)
NOT REQUIRED
14D. EXPIRATION DATE
5A. RESlDENCE
III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
YES
Approved Exception To SF 171
OMB No. 2900-0205
Estimated burden: 30 minutes
APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
1. OCCUPATION FOR WHICH APPLYING
A
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E LICENSED PHARMACIST OTHER (Specify)
B FREGISTERED RESPIRATORY THERAPIST PHYSICIAN ASSISTANT
EXPANDED-FUNCTION DENTAL AUXILIARYC LICENSED PHYSICAL THERAPIST G
D HLICENSED PRACTICAL/VOCATIONAL NURSE OCCUPATIONAL THERAPIST
2. NAME (Last, First, Middle)
4. PRESENT ADDRESS (Include ZIP Code)
5. TELEPHONE NUMBER (Include Area Code)
5B. BUSINESS
7. PLACE OF BIRTH (City)6. DATE OF BIRTH
9A. CITIZENSHIP 9B. COUNTRY OF WHICH YOU ARE A CITIZEN
10C. DATE FILED10B. NAME OF OFFICE WHERE FILED
10A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
YES NO
12. DATE AVAILABLE FOR EMPLOYMENT11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
I - ACTIVE MILITARY DUTY
13B. DATE TO 13C. SERIAL OR SERVICE NO. 13D. BRANCH OF SERVICE
13E. TYPE OF DISCHARGE
13A. DATE FROM
(Explain on
separate sheet)
II - LICENSURE, DEA CERTIFICATION, REGISTRATION AND CLINICAL PRIVILEGES (As applicable)
14A. LIST ALL STATES/TERRITORIES IN WHICH
YOU ARE NOW OR HAVE EVER BEEN LICENSED
(If not held now, explain on separate sheet)
14B. LICENSE NO.
NO
(If "YES" explain
on separate sheet)
15B. DO YOU HAVE PENDING OR HAVE YOU EVER
HAD A STATE LICENSE TO PRACTICE REVOKED,
SUSPENDED, DENIED, RESTRICTED, LIMITED, OR
ISSUED/PLACED ON A PROBATIONAL STATUS OR
VOLUNTARILY RELINQUISHED
15A. ARE YOU FULLY LICENSED IN EVERY STATE IN
WHICH YOU RECEIVED A LICENSE
15C. HAVE YOU EVER HELD A REGISTRATION TO
PRACTICE THAT IS NO LONGER HELD OR
CURRENT
(If restricted, limited or
probational in any State(s),
explain on separate sheet)
(If "YES" explain
on separate sheet)
NOYESNOT APPLICABLE NONOYES
16D. HAS ACTION EVER BEEN TAKEN
AGAINST YOUR CERTIFICATION OR
REGISTRATION
16C. WHAT IS YOUR REGISTRY/
CERTIFICATION NUMBER
(If "YES" explain
on separate sheet)
NO
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS
OR CLINICAL PRIVILEGES EVER BEEN DENIED,
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
VOLUNTARILY RELINQUISHED
17B. NAME OF CURRENT OR MOST RECENT
INSTITUTION, AGENCY OR ORGANIZATION WHERE
HELD
17A. DO YOU CURRENTLY HAVE OR HAVE YOU
EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH
CARE INSTITUTION, AGENCY OR ORGANIZATION
(If "YES" complete
Item 17B)
NO NOYES
VA FORM
JUN 2006 (R)
CERTIFICATION:
I certify that I have verified licensure and registration with State boards, and sighted visa or evidence of
citizenship. Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO:
VISACERTIFICATION OR REGISTRATION
CURRENT OR MOST RECENT CLINICAL PRIVILEGESNATURALIZED CITIZENSHIP
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGESLICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
19B. TITLE 19C. DATE (MONTH, DAY, YEAR)19A. SIGNATURE OF AUTHORIZED OFFICIAL
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.
INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Affairs to
determine your eligibility for appointment in Veterans Health Administration.
Type, or print in ink. If additional space is required, please attach a separate sheet and refer to items being answered by number.
YES
10-2850c
(If "YES" complete items 10B and 10C)
YES
YES
PAGE 1
SPECIALTY (Identify Below)GENERAL PRACTICE
COUNTRYZIP CODESTATECITY
APT. NO.STREET ADDRESS 2
COUNTRYSTATE
NOT A U.S. CITIZEN (Complete item 9B)NATURALIZED U.S. CITIZENU.S. CITIZEN BY BIRTH
OTHER HONORABLE
(If "YES" explain
on separate sheet)
EXISTING STOCK OF VA FORM 10-2850c, SEP 1998, WILL BE USED.
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Application for Associated Health Occupations
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