Va Form 10-2850 - Application For Physicians, Dentists, Podiatrists, Optometrists And Chiropractors Page 3
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429. LIST ALL PROFESSIONAL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS AND FELLOWSHIPS (If
additional space is required, attach separate sheet)
30. REFERENCES: List four persons, preferably in your specialty, living in the United States who are not related to you by blood or marriage and who
have been in a position to judge your professional qualifications during the past five years.
30A. NAME
30B. ADDRESS (Street, City, State and ZIP Code)
30C. AREA CODE/PHONE NO. 30D. BUSINESS OR OCCUPATION
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER
YES
NO
ITEM NO.
Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based
31.
upon military, Federal civilian, or District of Columbia service?
Does the Department of Veterans Affairs (VA) employ any relative of yours (by blood or marriage)? If "YES", give
32.
separately such 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.)
33.
(As a provider of health care services, 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 36, 37 or 38 is "YES" give for each offense: (1) date;
(2) charge; (3) place; (4) court and (5) action taken. When answering item 36 or 37, 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?
34.
Within the last five years have you resigned or retired from a position after being notified you would be disciplined or
35.
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
36.
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
37.
now under charges for any offense against the law not included in 36 above?
While in the military service were you ever convicted by a general court-martial?
38.
If you were in the military service as a physician, dentist, podiatrist, optometrist, or chiropractor, did you ever receive a
39.
non-judicial 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.)
40.
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.
XII - 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
CERTIFICATION:
STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.
41A. SIGNATURE OF APPLICANT (Sign in dark ink)
41B. DATE (Month, Day,Year)
PAGE 3
VA FORM
10-2850
JUN 2006 (R)
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