Va Form 10-2850c - Application For Associated Health Occupations
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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)
B
REGISTERED RESPIRATORY THERAPIST
F
PHYSICIAN ASSISTANT
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
CITY
STATE
ZIP CODE
COUNTRY
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
14B. LICENSE NO.
14D. EXPIRATION DATE
YOU ARE NOW OR HAVE EVER BEEN LICENSED
(If "NO" explain on separate sheet)
(If not held now, explain on separate sheet)
YES
NO
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE IN
15C. HAVE YOU EVER HELD A REGISTRATION TO
15B. DO YOU HAVE PENDING OR HAVE YOU EVER
WHICH YOU RECEIVED A LICENSE
PRACTICE THAT IS NO LONGER HELD OR
HAD A STATE LICENSE TO PRACTICE REVOKED,
(If restricted, limited or
CURRENT
probational in any State(s),
SUSPENDED, DENIED, RESTRICTED, LIMITED, OR
explain on separate sheet)
ISSUED/PLACED ON A PROBATIONAL STATUS OR
VOLUNTARILY RELINQUISHED
(If "YES" explain
(If "YES" explain
YES
NO
NOT APPLICABLE
YES
NO
YES
NO
on separate sheet)
on separate sheet)
16A. NAME THE CERTIFYING BODY
16B. DATE OF MOST RECENT
16C. WHAT IS YOUR REGISTRY/
16D. HAS ACTION EVER BEEN TAKEN
FOR YOUR HEALTH OCCUPATION
REGISTRATION/ CERTIFICATION (Give
CERTIFICATION NUMBER
AGAINST YOUR CERTIFICATION OR
Month and Year)
REGISTRATION
(If "YES" explain
YES
NO
on separate sheet)
17A. DO YOU CURRENTLY HAVE OR HAVE YOU
17B. NAME OF CURRENT OR MOST RECENT
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS
EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH
INSTITUTION, AGENCY OR ORGANIZATION WHERE
OR CLINICAL PRIVILEGES EVER BEEN DENIED,
CARE INSTITUTION, AGENCY OR ORGANIZATION
HELD
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
VOLUNTARILY RELINQUISHED
(If "YES" complete
(If "YES" explain
YES
NO
YES
NO
Item 17B)
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).
18. EVIDENCE HAS BEEN SIGHTED 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)
PAGE 1
VA FORM
10-2850c
EXISTING STOCK OF VA FORM 10-2850c, SEP 1998, WILL BE USED.
JUN 2006 (R)
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