Va Form 4682-2 - Certification Of Licensure, Registration, Or Bar Membership

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CERTIFICATION OF LICENSURE, REGISTRATION,

OR BAR MEMBERSHIP

PRIVACY ACT NOTICE: The information requested is voluntary and is solicited under authority of Chapter 73, Title 38, U.S.C., Sections 4105 and 4106, or

Title 5, U.S.C., Sections 3301, 3302, 3304, and 3320. It will be used to determine your current qualifications for a specific position. If you decline to provide the

information requested, it may result in disqualification for the position.

INSTRUCTION TO EMPLOYEE: Please complete items 8A through 10.

1. STATION NAME AND LOCATION

2. STATION NO.

3. DUTY STATION

4. EMPLOYEE NAME (Last, first, middle)

5. SOCIAL SECURITY NO.

6. POSITION TITLE

7. ORGANIZATION (Department or staff office, service, division, etc.)

CURRENT LICENSE, REGISTRATION, OR BAR MEMBERSHIP

8A. STATE

8B. NUMBER

8C. DATE ISSUED

8D. EXPIRATION DATE

CERTIFICATION: I certify that I have a current license, registration, or bar membership as described above.

9. SIGNATURE OF EMPLOYEE

10. DATE

The information above has been verified.

11. SIGNATURE AND TITLE OF VERIFYING OFFICIAL

12. DATE

4682-2

PERSONNEL FOLDER 1

VA FORM

SEP 2002(R)