i~?f'i/.Vt~ S?:Jtl.

~il~~

----

{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