10-2850c - Application For Associated Health Occupations

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Approved Exception To SF 171
Use TAB key or Mouse to move between data fields
OMB No. 2900-0205
Estimated burden: 30 minutes
APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
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.
1. OCCUPATION FOR WHICH APPLYING
A
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E
LICENSED PHARMACIST
OTHER (Specify)
REGISTERED RESPIRATORY THERAPIST
PHYSICIAN ASSISTANT
B
F
C
LICENSED PHYSICAL THERAPIST
G
EXPANDED-FUNCTION DENTAL AUXILIARY
D
LICENSED PRACTICAL/VOCATIONAL NURSE
H
OCCUPATIONAL THERAPIST
2. NAME (Last, First, Middle)
3. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
4. PRESENT ADDRESS (Include ZIP Code)
STREET ADDRESS 2
APT. NO.
5. TELEPHONE NUMBER (Include Area Code)
5A. RESlDENCE
5B. BUSINESS
STATE
ZIP CODE
COUNTRY
CITY
6. DATE OF BIRTH
7. PLACE OF BIRTH (City)
STATE
COUNTRY
8. SOCIAL SECURITY NUMBER
9A. CITIZENSHIP
9B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 9B)
10A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
10B. NAME OF OFFICE WHERE FILED
10C. DATE FILED
YES
NO
(If "YES" complete items 10B and 10C)
11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
12. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
13A. DATE FROM
13B. DATE TO
13C. SERIAL OR SERVICE NO.
13D. BRANCH OF SERVICE
13E. TYPE OF DISCHARGE
(Explain on
HONORABLE
OTHER
separate sheet)
II - LICENSURE, DEA CERTIFICATION, REGISTRATION AND CLINICAL PRIVILEGES (As applicable)
14C. CURRENT REGISTRATION
14A. LIST ALL STATES/TERRITORIES IN WHICH
(If "NO" explain on separate sheet)
YOU ARE NOW OR HAVE EVER BEEN LICENSED
14B. LICENSE NO.
14D. EXPIRATION DATE
(If not held now, explain on separate sheet)
YES
NO
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE
15B. DO YOU HAVE PENDING OR HAVE YOU EVER HAD A
15C. HAVE YOU EVER HELD A
IN WHICH YOU RECEIVED A LICENSE
STATE LICENSE TO PRACTICE REVOKED, SUSPENDED,
REGISTRATION TO PRACTICE THAT IS
(If restricted, limited or probational in any State(s),
DENIED, RESTRICTED, LIMITED, OR ISSUED/PLACED ON A
NO LONGER HELD OR CURRENT
explain on separate sheet)
PROBATIONAL STATUS OR VOLUNTARILY RELINQUISHED
(If "YES" explain on
NO
NOT APPLICABLE
NO
(If "YES" explain on separate sheet)
NO
YES
YES
YES
separate sheet)
16A. NAME THE CERTIFYING BODY
16B. DATE OF MOST RECENT
16C. WHAT IS YOUR REGISTRY/
16D. HAS ACTION EVER BEEN TAKEN AGAINST
FOR YOUR HEALTH
REGISTRATION/CERTIFICATION
CERTIFICATION NUMBER
YOUR CERTIFICATION OR REGISTRATION
OCCUPATION
(Give Month and Year)
(If "YES" explain on
NO
YES
separate sheet)
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR
17A. DO YOU CURRENTLY HAVE OR HAVE YOU EVER
17B. NAME OF CURRENT OR MOST RECENT
CLINICAL PRIVILEGES EVER BEEN DENIED,
HAD CLINICAL PRIVILEGES AT ANY HEALTH
INSTITUTION, AGENCY OR
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
CARE INSTITUTION, AGENCY OR ORGANIZATION
ORGANIZATION WHERE HELD
VOLUNTARILY RELINQUISHED
(If "YES" explain on
YES
NO
(If "YES" complete Item 17B)
YES
NO
separate sheet)
III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
I certify that I have verified licensure and registration with State boards, and cited visa or evidence of citizenship.
CERTIFICATION:
Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN CITED IN REGARDS TO:
CERTIFICATION OR REGISTRATION
VISA
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
LICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
19A. SIGNATURE OF AUTHORIZED OFFICIAL
19B. TITLE
19C. DATE (MONTH, DAY, YEAR)
VA FORM
10-2850c
PAGE 1
EXISTING STOCK OF VA FORM 10-2850c, JUN 2006, WILL BE USED.
NOV 2016 (R)

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