Va Form 10-2850d - Application For Health Professions Trainees
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4OMB Number: 2900-0205
Estimated Burden: 30 minutes
APPLICATION FOR HEALTH PROFESSIONS TRAINEES
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 (VA) to
determine your eligibility for appointment. Type or print in ink. If additional space is needed, please attach a separate sheet and refer to items being answered
by number. Applications for clinical training programs may require additional information. All information required by the training program to which you are
applying, as well as information requested on all application forms, must be included.
VA must protect the safety of our patients. Therefore, at some point in the appointment process, you will be asked questions about your physical and mental
health. This includes questions as to whether you have received tuberculin testing, hepatitis B vaccinations or any other vaccinations.
1A. NAME (Last, First, Middle)
1B. OTHER NAMES USED
2. PRESENT ADDRESS (Include ZIP Code)
3A - PRIMARY PHONE (Include area code)
3B - ALTERNATE PHONE (Include area code)
4. SOCIAL SECURITY NUMBER
5A. PRIMARY EMAIL ADDRESS
5B. ALTERNATE EMAIL ADDRESS
6. DATE OF BIRTH (mm/dd/yyyy)
7B. VA TRAINING START DATE (mm/yyyy)
7C. VA TRAINING END DATE (mm/yyyy)
7A. VA TRAINING FACILITY (City, State)
UNKNOWN
UNKNOWN
II - U.S. MILITARY DUTY STATUS
8A. ARE YOU NOW IN U.S. MILITARY?
8B. ARE YOU IN THE RESERVES OR NATIONAL GUARD?
8C. BRANCH OF SERVICE
YES
NO
YES
NO
(If YES, complete 8c)
(If YES, complete 8c)
III - CITIZENSHIP
9B. COUNTRY OF CITIZENSHIP
9A. CITIZENSHIP
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 9B)
NOTE: Complete items 10A, 10B, 10C, or 10D ONLY if you are NOT a U.S. citizen.
10A. IMMIGRANT
10B. EXCHANGE VISITOR
10C. OTHER NON-IMMIGRANT
10D. FORM DS2019
DO YOU HAVE A VALID DS2019?
"A" NUMBER
VISA TYPE
VISA NUMBER
VISA TYPE
VISA NUMBER
YES
NO
DATE
ISSUE DATE
EXPIRATION DATE
EXPIRATION DATE
ISSUE DATE
DATE OF LAST VALIDATION (MM/DD/YYYY)
IV- THIS SECTION TO BE COMPLETED BY DESIGNATED EDUCATION OFFICER (DEO) OR DESIGNEE
NO
YES
11A. The trainee has met all of the criteria of the Trainee Qualifications & Credentials Verification Letter (TQCVL).
NO
YES
11B. Incomplete items on the TQCVL have been addressed and resolved.
11C. Special attention has been given to the following items from the application forms.
11D. Comments:
YES
NO
11E. This applicant has been approved for appointment.
11F. Comments:
12A. SIGNATURE OF FACILITY DESIGNATED EDUCATION OFFICER OR DESIGNEE
12B. TITLE
12C. DATE
VA FORM 10-2850D
PAGE 1 OF 4
NOV 2011
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