Va Form 10-2850 - Application For Physicians, Dentists, Podiatrists, Optometrists And Chiropractors
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Use TAB key or Mouse to move between data fields
OMB No. 2900-0205
Estimated burden: 30 minutes
APPLICATION FOR PHYSICIANS, DENTISTS, PODIATRISTS, OPTOMETRISTS AND CHIROPRACTORS
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. NAME (Last, First, Middle)
2. APPLICATION FOR (Check one)
SPECIALTY (Identify below)
GENERAL PRACTICE
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 (City)
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)
9A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
9B. NAME OF OFFICE WHERE FILED
9C. DATE FILED
YES (If "YES", complete items 9B and 9C)
NO
10. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
11. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
12A. DATE FROM
12B. DATE TO
12D. BRANCH OF SERVICE 12E. TYPE OF DISCHARGE
12C. SERIAL OR SERVICE NO.
HONORABLE
OTHER (Explain on seperate sheet)
II - LICENSURE, DEA/STATE CERTIFICATION, SPECIALTY BOARDS AND CLINICAL PRIVILEGES
13C. CURRENT REGISTRATION
13A. LIST ALL STATES/TERRITORIES/COMMONWEALTHS OF THE U. S.
13D. EXPIRATION
(If "NO" explain on separate sheet)
13B. LICENSE NO.
OR THE DISTRICT OF COLUMBIA, WHERE YOU ARE OR HAVE EVER
DATE
BEEN LICENSED (If not held now, explain on a separate sheet)
YES
NO
NOT REQUIRED
14. DO YOU HAVE PENDING, OR HAVE YOU
15A. NUMBER OF CURRENT OR MOST
15B. DATE OF
15C. HAVE YOU EVER HAD A DEA
EVER HAD ANY LICENSE REVOKED
RECENT DEA (DRUG ENFORCEMENT
EXPIRATION
CERTIFICATE OR STATE LICENSE/PERMIT
SUSPENDED, DENIED, RESTRICTED, LIMITED
ADMINISTRATION) CERTIFICATE
REVOKED, SUSPENDED, LIMITED,
OR ISSUED/PLACED IN A PROBATIONAL
AND/OR STATE LICENSE/PERMIT TO
RESTRICTED IN ANY WAY OR
STATUS OR VOLUNTARILY RELINQUISHED
PRESCRIBE CONTROLLED SUBSTANCES
VOLUNTARILY RELINQUISHED
YES (If "YES", explain on seperate sheet)
YES (If "YES", explain on seperate sheet)
NO
NO
16A. ARE YOU CERTIFIED BY AN AMERICAN
16B. DATE
16C. SPECIAL CERTIFICATIONS (Recognized
16D. DATE
by American Board after exam)
SPECIALTY BOARD (General Certification)
YES (If "YES", provide names of boards below)
YES (If "YES", provide names of boards below)
NO
NO
16E. LIST AND PROVIDE DETAILS OF ALL CERTIFICATIONS BY OTHER THAN AN AMERICAN SPECIALTY BOARD (Use separate sheet if more space is necessary)
17A. DO YOU CURRENTLY HAVE OR HAVE
17B. NAME AND ADDRESS OF CURRENT OR MOST RECENT
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS
INSTITUTION, AGENCY OR ORGANIZATION WHERE HELD
YOU EVER HAD CLINICAL PRIVILEGES AT
OR CLINICAL PRIVILEGES EVER BEEN DENIED,
ANY HEALTH CARE INSTITUTION OR
REVOKED, SUSPENDED, REDUCED, LIMITED, NOT
AGENCY
RENEWED, OR VOLUNTARILY RELINQUISHED
YES (If "YES", complete item 17B)
NO
YES (If "YES", explain on seperate sheet)
NO
III - THIS SECTION TO BE COMPLETED BY THE CHIEF OF STAFF
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:
19A. SIGNATURE OF CHIEF OF STAFF
19B. DATE
BOARD
CERTIFICATION
CURRENT
FULL
NATURALIZED
REGISTRATION
VISA
LICENSURE
CITIZENSHIP
(All States)
PAGE 1
VA FORM
10-2850
EXISTING STOCK OF VA FORM 10-2850, JUL 2004, WILL BE USED.
JUN 2006 (R)
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