Fillable Va Form 10-2850b - Application For Residents printable pdf download

Approved Exception To SF 171

OMB No. 2900-0205

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Estimated burden: 30 minutes

APPLICATION FOR RESIDENTS

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.

2. APPLICATION FOR (Check one)

1. NAME (Last, First, Middle)

GENERAL PRACTICE

SPECIALTY (Identify Below)

3. PRESENT ADDRESS (Street Address 1)

STREET ADDRESS 2

APT. NO.

4. TELEPHONE NUMBER (Include Area Code)

4A. RESIDENCE

4B. BUSINESS

CITY

STATE

ZIP CODE

COUNTRY

5. DATE OF BIRTH

6. PLACE OF BIRTH

STATE

COUNTRY

7. SOCIAL SECURITY NUMBER

8A. CITIZENSHIP

8B. COUNTRY OF WHICH YOU ARE A CITIZEN

U.S. CITIZEN BY BIRTH

NATURALIZED U.S. CITIZEN

NOT A U.S. CITIZEN (Complete item 8B)

9. DESIRED STARTING DATE OF RESIDENCY

10. ARE YOU A PARTICIPANT IN THE CURRENT NATIONAL RESIDENT MATCHING PROGRAM

YES

11A. ARE YOU A DIPLOMATE OF THE NATIONAL BOARD OF MEDICAL EXAMINERS 11B. NUMBER OF DIPLOMA

11C. DATE OF DIPLOMA

YES

(If "YES" complete items 11B and 11C)

NOTE: Complete item 12A, 12B, 12C, or 12D, ONLY if you are not a U.S. Citizen.

12D. FORM IAP-66

12A. IMMIGRANT

12B. EXCHANGE VISITOR

12C. OTHER NON-IMMIGRANT

"A" NUMBER

VISA TYPE

VISA NUMBER

VISA TYPE

VISA NUMBER

DO YOU HAVE A VALID FORM IAP-66

YES

DATE

ISSUE DATE

EXPIRATION DATE

ISSUE DATE

EXPIRATION DATE

DATE OF LAST VALIDATION

I - ACTIVE U.S. MILITARY DUTY

13A. DATE FROM

13B. DATE TO

13C. SERIAL OR SERVICE NO.

13D. BRANCH OF SERVICE

13E. TYPE OF DISCHARGE

HONORABLE

OTHER (Explain on seperate sheet)

II - LICENSURE, DEA CERTIFICATION AND CLINICAL PRIVILEGES

14A. LIST ALL STATES/TERRITORIES IN WHICH

14C. CURRENT REGISTRATION

14B. LICENSE NO.

YOU ARE NOW OR HAVE EVER BEEN LICENSED

(If "NO" explain on separate sheet)

14D. EXPIRATION DATE

(If not held now, explain on separate sheet)

NOT REQUIRED

YES

16A. NUMBER OF CURRENT OR

16B. DATE OF

17. HAVE YOU EVER HAD A DEA CERTIFICATE

15. DO YOU HAVE OR HAVE YOU EVER HAD

MOST RECENT DEA (DRUG

REVOKED, SUSPENDED, LIMITED, RESTRICTED IN

ANY LICENSE REVOKED, SUSPENDED,

EXPIRATION

ENFORCEMENT ADMINISTRATION)

ANY WAY OR VOLUNTARILY RELINQUISHED

DENIED, RESTRICTED, LIMITED OR

CERTIFICATE

ISSUED/PLACED IN A PROBATIONAL

STATUS OR VOLUNTARILY RELINQUISHED

(If "YES" explain

YES

on separate sheet)

18A. DO YOU CURRENTLY HAVE OR HAVE

18B. NAME AND ADDRESS OF CURRENT OR MOST RECENT

18C. HAVE ANY OF YOUR CLINICAL PRIVILEGES

YOU EVER HAD CLINICAL PRIVILEGES AT ANY

INSTITUTION, AGENCY OR ORGANIZATION WHERE HELD

EVER BEEN DENIED, REVOKED, SUSPENDED,

HEALTH CARE INSTITUTION OR AGENCY

REDUCED, LIMITED, NOT RENEWED, OR

VOLUNTARILY RELINQUISHED

(If "YES" complete

(If "YES" explain

YES

Item 18B)

on 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 sighted visa or evidence of

CERTIFICATION:

citizenship. Board certification has been verified (if appropriate).

19. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO:

FULL LICENSURE / REGISTRATION

NATURALIZED CITIZENSHIP

ECFMG CERTIFICATION

VISA

CLERKSHIPS TAKEN IN THE U.S.

RESIDENT CREDENTIAL VERIFICATION LETTER

20A. SIGNATURE OF FACILITY DIRECTOR OR DESIGNEE

20B. TITLE

20C. DATE

PAGE 1

VA FORM

10-2850b

EXISTING STOCK OF VA FORM 10-2850b, SEP 1998, WILL BE USED.

JUN 2006 (R)

Va Form 10-2850b - Application For Residents

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