i~?f'i/.Vt~ S?:Jtl.
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{fl Sf I i J
)11 Mmuc.:-t
F"1mm~J b11rJ~,,
--
Department of Veterans Affairs
APPLICATION FOR PHYSICIANS, DENTISTS, PODrATRISTS, OPTOMETRISTS AND CHIROPRACTORS
'HI \S-1 P u;r fOR P\l't:R\\ ORK REOt l 110' .-\(I, PRJ\'AC\ \('T .-\'\0 l'ilOR\f .\ 110' -\ROt I OlSl lll'l RE:
I~STRL:CTIOi':S .
\Ol R S()('L\l SH l RIT\ '\l \IBl R
Please submit
this appl i cahon fumishing all information in sufficient detail to enable the Department of \'cterans
\ ffairs to determine )-Our cli~ibility for appointment in Vcterdns llealth -\dministration
f) pe. or print tn ink. If add ilaonal space is required. please attach a separate sheet and refer toll ems being answered b) number
NAI.IE tLast Fst Moddle)
2 APPUCAnON FOR (Check one)
SPECIALTY tldenbly l>elOW)
GENERAL PRACTICE
I
JAMES
~i!'RTAGH
3 PRESENT ADDRESS (SI!eet Address 1)
uC..HN
STREET ADDRESS 2
APT tO
4 TELEPHONE NUMBER (lnduda Area Codt'J
20 HARBOUR OVERLOOK,
C Tl
STATE
ALPf!.J..RETTA
ZIP CODE
16 PLACE OF BIRTH (GrtyJ
5 DATE OF BIRTH
06!12/ 1958
STATE
TOLEDO
COUNTRf
274
SA CITIZENSHIP
rx
NU~BER
':>6 7':$.o6
8B COUNTRY OF V\MICH YOU ARE A
U S CITIZEN BY BIRTH
NATURALIZED
us
CITlZEN
~lOT
9.0. HAVE YOU EVER FILED APPLICATION FOR APPOINTMErn IN THE VA
SOCIAL SECURITY
USA
OH
149 BUSII~ESS
t 1-62640.2)
USA
3000'>
GA
4A RESIDENCE
COUNTRY
YES (If "YES" complete 1tems 98 and 9C)
19CDATE FilED
't/c 'l
'1 DATE AVAlt::A'BLE FOR EMPLOYMENT
. ,.
r 2C SER IAl OR SERVICE NO r2D BRAI<CH OF SERVICE
1'2B DATE TO
CIT!ZE~I
I)_') l:r
.... l ('.;.. ,
I ACTIVE MILITARY DUTY
12A DATE FROM
aem 8B)
98 NAIJE OF OFFICE WHERE FILED
1\iO
10 .....l-IEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
.u.~
A lJ S CITIZEN tComple'e
12E TYPE OF DISCHARGE
1I
HONORABLE
OTHER (Expla<n
on seperate >lt:ell
II LICENSURE, DEAISTATE CERTIFICATION , SPECIALTY BOARDS AND CLINICAL PRIVILEGES
13A LIST All STATES!TERRITORIES/COMMONVVEALTHS OF THE U S
OR THE DISTRICT OF COLUMBIA. VVHERE YOU ARE OR HAVE EVER
BEEN liCENSED til not held now. explan on a separate sneel)
138. LICENSE NO
SP..
o~.;o3!
3A
CHOJl
TX
G6679
T''
86679
3I~
0<1<1011
GA
044031
14 DO YOU HAVE PENDING. OR HAVE YOU
EVER rlAD ANY LICENSE REVOKED
SUSPENDED. DENIED. RESTRICTED. LIMITED
OR ISSUED/PLACED IN A PROBATIONAL
STATUS OR VOLUNTARILY RELINQUISHED
rx
15A NUMBER OF CURRENT OR MOST
RECENT DEA (DRUG ENFORCEMENT
ADMINISTRA TIONI CERTIFICATE
ANOiOR STATE L CENSEIPERMIT TO
PRESCRIBE CONTROLLED SUBSTANCES
13C. CURRENT REGISTRATION
(If " NO" uplam on separate sheet)
YES
NO
rx
rx
rx
I
I
I
IX
IX
IX
I
I
I
I
I
I
16A ARE YOU CERTIFIED BY AN AMERICAN
SPECIALTY BOARD (General CertificatiOn)
IX
YES (If "YES". prov1de names of boards belowl
NO
rx
l/10/2011
16B DATE
YES(If 'YES
I
I
YES
(II
~/2;20lt.l
1 i/Bi2<J<J9
11/8i21)09
6/]0/2009
i:>/3/200'3
explain on seperate sheet1
NO
loG SPECIAL CERTIFICATIONS (Recogmzed
by Amencan Board after el(am)
9 ll/1985
6/}012011
15C HAVE YOU EVER HAD A DEA
CERT IFICATE OR STATE UCENSEIPERMIT
REVOKED. SUSPENDED, . IMITED,
RESTRICTED tN ANY WAY OR
VOLUNTARILY REliNQUISHED
15B DATE OF
EXPIRATION
BM7599206
NOT REQUIRED
I
I
YES (If "YES' explam on seperate sheel)
NO
13D EXPIRATION
DATE
10 DATE
YES' provde names of boards below)
NO
16E LIST AND PROVIDE DETAILS OF ALL CERTIFICATIONS BY OTHER THAN AN AMERICAN SPECIALTY BOARD (Use separate sheet of more space 1s necessary)
17A DO YOU CURRENTLY HAVE OR HAVE
YOU EVER HAD CLINICAL PRIVILEGES AT
ANY HEALTH CARE INSTITUTION OR
AGENCY
fX
YES (If ''YES", complete 11em 17B)
17B NAME AND ADDRESS OF CURRENT OR MOST RECENT
INSTITUTION AGENCY OR ORGANIZATION WHERE HELD
NO
Ill THIS SECTION
CERTIFICATION:
I certifY that
FULL
LICENSURE
YM~to~ (R) 1 0-2850
Confidential
TO
BE COMPLETED BY THE
citizenship. Board certification 1\as
YES (If "Y ES", explam on seperate sheet!
fX
NO
CHIEF OF STAFF
I have verlffed licensure and registration with State boards, and sighted visa or evidence of
18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO
CURRENT
REGISTRATION
(IIJI Stales)
17C HAVE ANY OF YOUR STAFF APPOINTMENTS
OR CLI NI CAL PRIVILEGES EVER BEEN DENIED
REVOKED. SUSPENDED REDUCED, LIMITED. NOT
RENEWED. OR VOLUNTARILY RELINQUISHED
NATURALIZED
CITIZEfiiSHIP
been verified (If appropriate).
19A SIGNATURE OF CHIEF OF STAFF
BOARD
CERTIFICATION
198 DATE
VISA
EXISTING STOCK OF VA FORM 10-2850. JUL 2004, W ILL BE USED
PAGE
JM007754
IV P R O FESSIONA L LIABILITY INSURANCE
20C NA~~ES OF PRIOR
CARRIERS
20:. PRESENT PROFESSIONAL 20B DATE
liABiliTY lllSURANCE CARRIER COVERAGE BEGAN
200 DATES OF COVERAGE
FROM
TO
I
21 HAS ANY CARRIER EVER CANCELLED
DENIED OR REFUSED TO RENEW YOUR
INSURANCE
(lf.YES explarn
YES
NO
on separa!e sheet'
V PREPROFESSIONAL EDUCATION
22A flAME OF SCHOOL
22C SUBJECT
228 ADDRESS (City State and ZIP Code)
M~JOR
220 YEARS
ATTENDED
22E GRADUATED
MONTH
YEAR
22F
DEGREE
23C. YEARS
ATTENDED
230 GRADUATED
MONTH
YEAR
23E
DEGREE
VI PROFESSIONAL EDUCATION
234 NAME OF SCHOOL
UN: 1!ERSITY Of'
~liC ECJ
238 ADDRESS ICrty State and ZIP Co<lel
ANN ARBOR,
~n
48109
1982
06
~D
\:(Jflc f m
ir.:nh 2 1 thwugh 27.
1d.:nt11} >cnit:t ,,,
a paid
lcderal ~mplu~cc tndudml! s~nice \\tth V:\. I
i\ li lttar}
llf
l'uhhc
ll~.llth s~n
in: lnduJc
und tJ~ntil) 1ntansh1p or gcncml pradtcc rcs 1denci.:' f)() 'J(J I inc l ude c'lcm,hip>
VII RESIDENCY TRAINING AND FELLOWSHIPS SUBSEQUENT TO GRADUATIO N FROM PROFESSIONAL SCHOOL
24A NAME OF HOSPITAL
OR INSTITUliON
!lATIONAL lNSTITliTI CJ
24C
SPeCIALTY
24B ADDRESS tCIf State and ZiP Code.
BETHESDJ>.,
!40 3 r)3 2 2
Ml
ur:rJERS:;:TY OF MICHQ
ANN hRBOR,
PAF.KL.Z:..ND E0SPITAL
DALLAS,
TX 753S.O
!ARKLAND liOSPITAL
DI\LLAS,
TX
~8Hi9,
75390,
USA
us
24D
PG LEVEL
Ptdmonaq.
ra
luimonary
24E COMPLETED
MONTH
YEAR
1987
24F
110 or
MONTHS
LIJ
\!7
1986
12
Internal ~l qj
07
19BS
24
Internal Mqj
07
i983
12
VIII TEACHIN G AN D /OR RESEARCH ASSOC IATIONS AND APPOINTMENTS WITH PROFESSIONAL SCHOOL S
l5A INSTITUTION
258 ADDRESS (C<Iy Stale and ZIP Code)
26A INSTITUTIOii
26B ADDRESS (Cr!y Stale and ZIP Code)
25C POSITION
250 DATE FROM
25E DI<TE TO
26D. DATE FROM
26E DATE TO
IX VISITING STAFF HOSPITAL APPOINTMENTS
26C. POSITION
X PROFESSIONAL EXPERIENCE
271>, EMPLOYER
27B ADDRESS tCrly State and ZIP Code)
27E
27C POSITION
(Where applrcable. also 27D PARTTIMJ:
AVERAGE
specify whether General FULL
HOURS
practitioner or Specialrsl) TIME PER
WEEK
DUBLIN,
GA 31021,
USA
STAPF PHYSlC [J
VAI'IC
DUBLIN,
GA 31021,
USA
STAFF PilYSIC [J
'IAMC
DUBLIN,
Gl\ 11021,
USA
STAFF PHYSIC [J
VAMC
r
r
r
27F DATES EMPLOYED
FROM
ro
5/09
8/0~
5/09
6/09
4/09
S/09
XI- GENERAL INFORMATION
28 NAMES UNDER WHICH YOU WERE EMPLOYED IF DIFFE RENT FROM NAME GIVEN IN ITEM I
VA rDRM
JUN 2006 (R)
10-2850
Confidential
PAGE 2
JM007755
29 liS I ,\1 I I'HOII'-.">H)\, '\I l'liBf.IC\IIOl'S SCII.NIIIIC I'APIR'-.IIO!'>ORS. \\\AIH><., IU '>I <\RCII (iR .\'= I'>.\'\[) I I I I 0\\'SIJI!'<., !It
;~tllitrnual
sp..tcc is req111reJ. rllach ":par Jlt: \htctl
Se
cv
111 RFI+RL Cl s !. hl four p.:rson'i. prelerabl} in) our >t>edah). li\ ing in the l mrcd <.,t..tlc~
ha, ... b.cn 10 a phrlion h> juJg.: ~our professional qualilit.ali<>nS Juring th.- pJstli' c )<1rs
30A NAME
L\r
~
~h
c::rr\.L.~
r1
JOB ADDRESS (Street Ctty State and ZIP Co<lel
1\ r11
DUBLI!J VA...!C,
Dl"3l.IN,
1\ hn
~r 1\ l}i\1<..
"'"'~~B
Dr.
'";~rn.t..
Lr
I.ARPY DIAZ
fr6 'I:\
DUBLIN,
DUBLIN,
E'llORY UtlTVERSJTY ,
ATLAlTlA,
~!EDICINE,
1100 N.
72?03
CC'LLEGE,
300 BUSINESS OR OCCUPAT IN
I~{. Uft f! \1'
#'o)L
3Q 1 ~
~I
7'"'6-2223
CHTEF GF
;A 3\J3l.1
FAYETTEVIf,I.E,
40-l
80\i
7'>74
4 J;
1';.7
70~0
lhR!JIOL<lGY
.=\F.
!4 79)
OOCTOR
144 5016
YES
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER
ITEM NO
31 .
Do )>u rcl'ch.: or dn }UU ha\c a p.:mling apphcatiun for retirem.:nl or r~l<llncr p.n pension, nr nthcr .:nm~nsatiun ha.,cd
upt>ll militar} . I eJ~ral ci' iltan. or Distrid ull'nlumhia >Cn tee?
32.
l>>cs thc Ocpartnu:nt ol Vcternns \lfmr' IV \I cmplny an} rclati\.: ot ~llur.; th) hluvJ or marriage)'' II ''YI
.;epa rate!} '>U~h relatn .:'s ( I) full name. (1 I rc lalton,htp. I.~) VA p(lsrtion ami cmpln) m.:nt lvcallon
,\RI YOU \,OW OR 11 /\ VI YOi l LVI R BH:'\ INVOI VFD IN
s. )!I\ I!
NO
1(
ix
\D\Il:-.1~1
R \ 11\'I..I'ROII SSJO'lAI OR Jl ' I> It 1.\1
I'ROCJ fl>I;>..CiS IN \\'Ill< II \HII'R.<\t IICI 0. YOl R P'\R I J<., OR WI\S \Ill !iiD''tll "YJ<.;" !!tvc Jctal!,
tnlluJmg name of acflon'r prm:ccdmg> Jatc tiled. court ur rt:' ic\1 111g ag.:nc). anJ the statu~ ur dl.'ipo..;llion of Lase
co>nccrning all.-~ations, together '' uh y nur t!\J>IatMiiun nl the L lrl'llllP;tanc~' Ill\ >h cJ 1
33
JA ll o.- 1
'titiR IO'N
AL!::XANDE!<
rdalt:J tu ) 1111 h) blnud nr marriage an.! \\ hu
30C AREA CODE/PHONE NO
~-~('
lltll
-;A ;!OJ!
H~i:RS.::lt~
~t
;u.:
( .\s .1 pro\ 1dcr ul hc;lllh care ser. tees. \1.\ Ius an nblig.Htontoc\crctsc rc.>,onahlc .:an: 111 delenni!Hilf! that .tppltc<tnh ;n~
prnp.:rl) quahlicd ll is rc.:ognitcd that man) allegation' of prufcsswnal m.tlpratttrc <.tn: pro' en groundlc,s. An) wndu.;inn
.:nll<Crnmg )''ur anS\\l'r a' 11 rcl.uc, ln proli:s>illnal <.JUultlica!lnns \\illlx rnnJ~ unl~ alt..:r a lull C\.tluattmtol the
.: ir.;u mstances im oh cd )
\011 .. ,\ nm ill ton or a tliSlharge dtlC> n,,, nc.:,.;saril' nu:an) 011 .:annnl he appollrh:J Iho: n.llurc ol the lUll\ tllion or o:h;chargc tnd hn\\ lung ago 11
un:urn.:tf h in1ponan1 Cil\c all the fau "'that ;1 decmun can be mad.:. It )lin ans\wr illljlll!'lttln 3b. 37 or JX IS "'t I S'' gl\c ((or each offcn'c tl I d.11<
I 2 I ,-hargc. 13l plarc. I~) court and ( Sl act ron taken \\'hen anmcr ing tlem 'I(> or 17, ~ nu ma~ omit t l) trallic line-; lin \\ hid1 ) ou pmJ a line ol \ l UO Otl
nr k,s; (21 an) uffen~c c<>lll llltlled b.:fun: ~uur 18th hinhJa) "hid1 \\as finally ad_1uJicakJ in aJU'I!ntk court ur utH.kr a )UIIIh olli:nde1 l.m. t'll am
u>n\tLlltnlhc rc~orJ uf\\htlh h.t~ hccn ~\pungcd und~r l"cJ<ral or '-.tntchm ..111<1 tit an) tttll\ icttnn set a\iJ~ under the I edcr.tl Y.outlo ( 'orrcLIIItn-; \c!
ur snntlar 'itate authnrit)
34
Witlun the laslli\c ~car:> ha\c
been Jr~th..trgeJ from ;lit) po>IIJun tor an) rc<htm' 1
35.
\\ ithin the la<t fi\c )Cars ha\c you rcstgncJ vr r.:ltrcd from H posrllun alter being nHttlicd )nil .\IHlhl he o:lisctplinc.J or
discharged, m nfler qucsttuns ahoul ) our o.:IIIHl'alcnlllpctcnc.: \\ere rarscd''
36
llavc )UU n~r bc.:n cnn1 iclcJ. l(orkitcd coll<~tcra l , or arc }nU llCIII under charges li>r an~ lclony or ;ul\ lircanns nr cxplusl\es
tJtlCIISC agatnst the law':' (;\ JC(Illl) h dclinctl ,IS :til~ <>fknsc fllllltshabfc !11 imprisnnmen tti>r ,1 1.:111 C\c'tCding one )l!<lr J-out
Jocs not inclutk .my nflcnse l l.t>sJii<!d '"" nusJ~mcanur unJ.-r the ld\\S uta '>tal~ .tnd pttnish<tblc h) ,t term l!f tmprisnnrn~nt
ol t\\O yean. nr less )
)HI
37
During the pa'l ~even )Cars ha1c )Oil been convil'tcJ. imprisom:d. on prol'>.lliun or pamlc. or furlcttcd ~:ollatera l t>l arc 'tll>
ntm umlcr ~hargcs ll1r an} t>lfcnsc agan1st the 1<1\\ 1101 mclmlcJ in 36 abo1c''
38.
Whil~
39.
If you were in the milttary sen rrc ;rs a phy-;tcian. Jcnli~t . podiatrt~l nptnmctrist. or d11roprador. did
non-JUJictal puni:>hmcnt (Art1dc 15)''
in the nul ita~ sen rce \\ere
)<>U c1
cr comrctcd b~ a general coun-mant.ll"
)Oll
ever n:~ci": u
Are }HU dc lim1ncnt un any h.:dcrnl deht'l (Include dclmquencics ari~ing from I cdcrnlta'c~. loan-;, o\ e1 p<l) m~n1 ut hendits.
anJ other debts to the l I.S. (w\crnmcnt. plu-; dclimlh on an) h.:dctall) guar'nllccd 11r 1nsured ln<nr> such as s111d~nl and hom'
nwrtgage loans )
40.
If " Yes . explain on a ,;cpar:llt' -;heel the t) pc . length and amnunl of the ddtnqucrtt} or ddituli and steps )till arc taking 11>
u1rrcc1 error, nr repay the deht (,1\'C <111} tdcntllicatlt'll number' ''""c'atnl "rlh the debt and the .tdtlrcss of I he lcdcr<ll
ugcnc' rn v<>h
rx
r
r
lx
r
rr
D(
t>(
1-- -
,- ?<
cu
XII - SIGNATURE OF APPLICANT
NOll' '\ false statement on any purl of) our upplic<.ttion m.t) he grounds lor nut hinng.) nu nr for lermi n:ttmg
\I 5o,) ou m.t} he punished h) line or imprisonment (U.!->. CoJc l'itlc l8.Scdmrt l001)
10 dark~)
VA FORM
JUN 2006 (R)
10-2850
alicr
)<HI
bcgm IHtrk
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF. ALL OF MY
STATEMENTS ARE TRUE CORRECT COMPLETE AND MADE IN GOOD FAll H
CERTIFICATION:
411\ SIGNATURE OF APPLICANT (Sogn
}OU
~...,
nJ
'~_;(-;---;
(,
r1B
DATE (Month , Da1 Year)
~-
1- ("t l
PAGE 3
Confidential
JM007756
AUTHORIZATION FOR RELEASE OF INFORMATION
In urd.:r lnr the
I
l>cpanm~nt
nf \'ctnans .\11:111' I VAtlu assess ,mtf
1cnl~
Ill} .:thh:allunal l>.t.:l.gr:.ntn.l. prnk>,llllt,tl quahli~,;alion~ and wn.tl>tln~ li1
~nrl>) m,nt
i)(
,\uthoru.: \' \ ll' m ~c tnqumc., lnm:cming ,uch mlimnallun ah<>utmc '"Ill) pre\ hlh .:mpf.,~erhJ. Lurr.:nt ..:mpiiiJ l'l , cJtKallllnal
in,Uillti.rl'. State licensing l'<.Mtls. fmtessionalliabilil) msuran.:c carrie". nathnalpraoitioncr Jata b.ml... t\mcrr.::an '\kJical ,\ss.,.r.ttll>n
l't.>J~r;tlhtn ''' St.uc 1\kJicallloards. other prolc"unalu gani..:atinns andtnr pcr'ions. agcncic'. l'fgani/ahnn:, or tn>litullon; listed I>~ m e ll'
rcfcrctKI!>. anJ tu all) other apprnpnate s11ttrccs 111 11hnm V:\ ma~ he rcti:rrc.J h} thnse contallcd or deemed appnrnalt:
IX
t\uthur11c rclcitsc "' 'uch inlim11at1on .tnt! cop1es ul rclateJ 1ccurds and'nr J,cume!lts t<' \.\ tliu.th
fX
IX
Release frnm li.tl:>tftl\ all tftuo;c wlhlf1111\
Ilk
mform.IIIUil
hl \ ,\HI
gonJ fallh
JhJ \\t!hclllt malr(C HI
r.:sptlll'e
IH
sudt lllljUIIIC,, ~nJ
\uthorllc \' .\ lu discii)SC to 'u~h r~rson,, cmplo}er,, tn'tlllllltns. hoards nl agcnct<> tdcntil:- Ill!! .mdnthcr mlinnauun ah.ntt me 111 ct1.1hlc
\' \ "' make sudt llll.jlllrics
, .
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
Thr l'apernork ReductiOn \ct cf I 'J'J'i rc<jUlrl!s u, tu m>lll) ) ou lhatthl' mlurmatum c,lkctum i'i 111 ''''""!.liKe "11h the deaHUKc rcqutrcmcn" ol
'cdtvn 1507 ullhc Papcn\<rk Rctlucllcln Art nr lql)'i \\ c may not conduct or spttll>nr. and )Oil arc nul rc4uircJ 111 respond to, a ,nlkrtunnf
tnlurmat n unlcs' 11 di>pht}' a 'a ltd Ol\1 B numhcr \\ e anl~<ipat.: that thl' lime c\p.:mkJ h) .tli mdl\ ~thai,\\ hn mcht nunpkh: thts f(mn "111 <~\.:rage
<ll mmut.:' !Ius mdu,lcs the lillie it ''til take I< rc.l\1 '"'trucllmh. gather Ihe nccesS,lf) liJ,ts and fill nut the: linn
\\ I I fill~ II Y I he 1nlurmauon tcqu.:stetl <II Ih.: anachcd applic.tli"' ftmn an.l .-\uth,ullaftllll lir Rdc,HI.' uf lnlm!n.ttinn ""'fi.:ttcd llltda l1tk <!I.
I nu,.J St,llc> l uJ.:. ( haptcr' 7 3 ,tnd 7 I
l'l ({I'! l'il S \I\ ll l' 'F'> flu: inhmnaiHJII fCIJIIC,h:d on !he appltcutl(ln is ~nllcltcd prunaril) tn d..:tcnmnc '""f <llt,tltlicaiiHII> and 'ull.thilll} lir
II }OU arc cmpll>)cd b) the\'\. the inlimnauun \\Ill be u'cd It> milf..o: p.t) ami hcndil lich.:rmllt.JIIIlll'i :md. a.; nc.:essm~ 1111~r fllld
adnllni,trauon prurcsse' <.:an ted out 111 ac~ordant:c \\llh c.,tahli~hed rcg.ul;lltnns and the puhltsheJ nnli.:c I the sy~km ,,f rem rtf, "\pphc.llll> fc1
I mpln}nt~nt under I illc 18, l'.S C-V\" toZV \135)
cmpi11}111C:Ilt
Hill liN! I \I 'i lnlormatHJII 1111 lhc linn t>r Lhc ilmn 1l\clf'ma) he rekasc:d 1\lllhJUI )OUr prior u>n'icnt ntltstde llu: V.\ to another I t,bal. '>t.ll.: w
l.. c..al ,tgcnl'). !11 the Nallun.tl l'ra<.:tilttllt<:r Data Bank \\ h!'h "aJnuni,tcr.:cl b} the Department ol llcallh .tntllluman Sen ILcs. tn <;tak h<:cthlllg hnanh.
.111J ur appwpr~o~h: prolc~slonul organtnltt '"'or .tgctll.ICS Ill us>t>t the V .-\ in dctcrnunmg) cmr suttahtfn, lin hmng and !m ctnp!.t) men!. to 11e1 ioJi~.tll .'
1.:rtl~ n alua1c and update )llttr .:ltnt.:al pnvtkg~s anJ lin! II sUre status, tn report apparcmur ptllcn11al -.olatHHIS uf Ia" h prm tdc sl,tltsllcul data llp<>n
rrcp.:r rc<jucst. or to pw1 td.: tnf(mHallun to a ( ungrc>Sillll.tl orfin 111 resp<Hlsc loan llllllllr) matlc <tl yuur requc,( "iud1111lonn"t'"n Ilia) .tho be
rd.:as.:d \llthoul your pnor L'UIISCIII to h;J.:ral agcnct<'. St.tlc licensmg b>artls ur sunilar hrmrds cH .:nl tllcs, Ill conm:ction \\lth thc \ \\ rcportm!) tl
mlormation ct>nc.:mmg} our '~paratttlll or resignation ,ts a professional staiT member untkr drcumslanccs 11h1dt rabc
'"fii'U' cotKcrns uhout) our proli:ssional compl'l~ncc lnlormauon cnnccrmng pa) m.:nts rdal~tl tn malpradtce da1ms and advc"e ;u.:11om "htlh
.tlkll clllliGtl pri1 ilcg.:.; also may hc rcleoscd tn Stmc licensing hoards and the "iatwnall'radttion.:r 0.1ta Bani.. I he llllirnhltinn you "'PPh 111.1\ he
'erilied through a cum puler malchmg program at atl} l1mc.
I I'll ( IS ( )f N< tN-DlSll 0Sl 1 1~1. Sec st.llcment bel<\\ wnccnung tlisclosurc of)our ,onal s<Tllrtt) numhc1 IJt'odo,urc nllh.: >!her intnnuation"
\ulunldl) hcmr:\cr. liulurc tn prO\ iJc tht.- mfonnauon may dcla} or mo~kc impt>Ssihk the prop.:r appiKil!lllllof( i1 il \en 1ce ruk' and rc')!lllJIIIIII' and
\ ,\ personnel ptthdcs .mJ thu, ma) prl'\ en! ~ Clll from ubtaming employment cmpluy.:c' hcnclits. or llho:r o:ntltlcmcnh
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93579 SECTION 7(b)
01scln,ure ol }nurSSN (Mtlt,tl set:llttly number) IS mandatory'" ohtainthc cmpht)tnt:nt anJ relotctl h.:n~lih th.\1 )Oil arc 'ccl..mg )llhLHallun >l!hc
';'iN i~ authoritcd under the pro\ i\lvns ol I xccuti' cOrder 9.l97, dated November 22. I 9 13. I he o.;s:-.; is used as an !dcnlilicr throughc>ul )Our I cdct.tl
career from the tunc ol app ltcationlhrough rcttremcnl 11 ''ill be u~cd primarily lo idenlll~ your records. llw SSN alst' 11ill he usrd l>y I cder.ll.tgcnliCS
1nconncciHHI \\ nh lawlitl requc, ls for lnliJJmution abnut }IHJ fmm }OUr tonncr ..:mpht) cr~. cduo:auunal tn~tlltltlun> .111d linanc1alor llthcr organllilllon'
I he mtonn.1tion gathered through the usc of the numbe-r "Ill be used only as ncccs,ar} tn pcro;nnncl aJmtnlstration prPlCss~s c.trricd nultn acwnhtnLc
,, llh cslthli5hctl reg.ulaltllll' and puhltsh~J notic~s uf '''items (,f rcr.:unls I he <;SN also "11il>c us,d lor the selection 11f pcr"ms to be 1ndud.:d 111
''"tistintl >lltdlc' of personnel nwnugcmcnl mallcr> I he u~c c>l the 'iSN is made nr:,cs~ar~ heLaus~ of tit.: l.trgc ntnnhcr ol prco;.:nt und limncr I cJ.:ral
cmplo:- ccs ami applil'ants \\ ho ha\ c 1dcntkul name' and b1rth date; . ami \\hose 1dcntit1cs can unl) he dtsllngui~hcd b1 th.: ";<;1'\
VA FORM
JUN 200& !Ri
10-2850
Confidential
PAGE4
JM007757
