Fillable Va Form 10-2850b - Application For Residents (Page 3 of 4) in pdf

33A. VA FACILITY

33B. NAME OF AFFILIATED MEDICAL OR DENTAL SCHOOL

33C. DATE OF APPOINTMENT

33D. REMARKS

33E. SIGNATURE OF FACILITY DIRECTOR

33F. DATE

FINAL

APPROVAL

X - GENERAL INFORMATION

29. NAMES UNDER WHICH YOU WERE EMPLOYED, IF DIFFERENT FROM NAME GIVEN IN ITEM 1

30. LIST ALL PROFESSIONAL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS AND FELLOWSHIPS (If additional space is required,

attach separate sheet).

PLACE AN "X" IN APPROPRIATE SPACE. IF ''YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER

ITEM NO.

YES

Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based upon

34.

military, Federal civilian, or District of Columbia service?

Does the Department of Veterans Affairs employ any relative of yours (by blood or marriage)? If "YES" give separately such

35.

relative's (1) full name; (2) relationship; (3) VA position and employment location.

ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE, PROFESSIONAL OR JUDICIAL

PROCEEDINGS IN WHICH MALPRACTICE ON YOUR PART IS OR WAS ALLEGED? (If "YES" give details including

name of action or proceedings, date filed, court or reviewing agency, and the status or disposition of case concerning

allegations, together with your explanation of the circumstances involved.)

36.

(As a provider of health care services, the VA has an obligation to exercise reasonable care in determining that applicants are

properly qualified. It is recognized that many allegations of professional malpractice are proven groundless. Any conclusion

concerning your answer as it relates to professional qualifications will be made only after a full evaluation of the circumstances

involved.)

NOTE: A conviction or a discharge does not necessarily mean you cannot be appointed. The nature of the conviction or discharge and how long ago

it occurred is important. Give all the facts so that a decision can be made. If your answer to question 39, 40 or 41 is "YES" give for each offense: (1)

date; (2) charge; (3) place; (4) court and (5) action taken. When answering item 39 or 40, you may omit (1) traffic fines for which you paid a fine of

$100.00 or less; (2) any offense committed before your 18th birthday which was finally adjudicated in a juvenile court or under a youth offender

law; (3) any conviction the record of which has been expunged under Federal or State law; and (4) any conviction set aside under the Federal Youth

Corrections Act or similar State authority.

Within the last five years have you been discharged from any position for any reason?

37.

Within the last five years have you resigned or retired from a position after being notified you would be disciplined or

38.

discharged, or after questions about your clinical competence were raised?

Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives

offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but

39.

does not include any offense classified as a misdemeanor under the laws of a State and punishable by a term of imprisonment

of two years or less.)

During the past seven years have you been convicted, imprisoned, on probation or parole, or forfeited collateral, or are you

40.

now under charges for any offense against the law not included in 39 above?

While in the military service were you ever convicted by a general court-martial?

41.

If you were in the military service as a physician, dentist, podiatrist or optometrist, did you ever receive a non-judicial

42.

punishment (Article 15)?

Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits,

and other debts to the U.S. Government, plus defaults on any Federally guaranteed or insured loans such as student and home

mortgage loans.)

43.

If "Yes" explain on a separate sheet the type, length, and amount of the delinquency or default and steps you are taking to

correct errors or repay the debt. Give any identification numbers associated with the debt and the address of the Federal agency

involved.

Xl - SIGNATURE OF APPLICANT

NOTE: A false statement on any part of your application may be grounds for not hiring you, or for terminating you after you begin work. Also, you

may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF MY STATEMENTS

CERTIFICATION:

ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.

44A. SIGNATURE OF APPLICANT (Sign in dark ink)

44B. DATE (Month, Day,Year)

VA FORM

PAGE 3

10-2850b

JUN 2006 (R)

Va Form 10-2850b - Application For Residents Page 3

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