File APPLICANT(453) Data List
| APPLICANT NAME |
SOCIAL SECURITY NUMBER |
DATE OF BIRTH |
STREET ADDRESS |
CITY |
STATE |
ZIP CODE |
HOME TELEPHONE NUMBER |
DAYTIME TELEPHONE NUMBER |
APPOINTMENT DESIRED |
REFERENCE A |
A ADDRESS1 |
A ADDRESS2 |
A CITY |
A STATE |
A ZIP |
REFERENCE B |
B ADDRESS1 |
B ADDRESS2 |
B CITY |
B STATE |
B ZIP |
REFERENCE C |
C ADDRESS1 |
C ADDRESS2 |
C CITY |
C STATE |
C ZIP |
APP DATE |
INSURANCE CO |
SPECIALTY |
SERVICE |
MANDATORY TRAINING |
TYPE OF APPOINTMENT |
APPLICATION DATE |
CERTIFICATION |
PROFESSIONAL ORGANIZATION |
HONORS/OFFICES HELD |
VAF 10-2850 COMPLETE (Y/N) |
VAF 10-2850 SIGNED/COS (Y/N) |
VAF 10-2850 LICENSE DATA (Y/N) |
BOARD ELIGIBLE |
FSMB MSG. SENT |
LICENSES |
DEA # |
DEA EXPIRATION DATE |
STATE ISSUING DEA NUMBER |
DEA VERIFICATION |
DEA CHALLENGES (Y/N) |
V.A. EMPLOYMENT START DATE |
SERVICE COMPUTATION DATE |
END OF PROBATIONARY PERIOD |
PRIMARY DEGREE |
SCHOOL ATTENDED |
DATE REAPPRAISAL IS DUE |
CONTINUING EDUCATION PROGRAM |
ALIEN VISA |
FINAL STATUS OF FILE |
FINAL STATUS COMMENTS |
CLINICAL BACKGROUND |
ECFMG CERT. ISSUED |
ECFMG VERIFICATION |
ECFMG CERTIFICATE # |
FSMB SCREENING REQUEST DATE |
HEALTH STATEMENT,APPLICANT |
HEALTH STATEMENT,COLLEAGUE |
DATE REFERENCE RECEIVED |
BYLAWS AGREEMENT |
RECOMMENDATION SIGNATURES |
LICENSURE CHALLENGES ? |
PERTINENT CLINICAL INFORMATION |
CLIN PRIVILEGES CHALLENGES ? |
NPDB QUERIED ? |
DATE SENT TO NPDB ? |
DATE REC'D FROM NPDB |
RESULTS OF QUERY ? |
PLACE OF BIRTH |
VA CAUTIONARY LIST CHECKED? |
INTERNSHIP/RESIDENCY |
CONTROL/SUBSTANCE CERT (Y/N) |
CITIZENSHIP |