VA Form 10-2850c Application for Associated Health Occupations

What Is a VA Form 10-2850C?

VA Form 10-2850C, Application for Associated Health Occupations is a form used to apply for a job in the associated healthcare occupations within the Department of Veterans Affairs (VA) and its sub-agencies: the department's central office, the Veterans Health Administration, the Veterans Benefits Administration, and the National Cemetery Administration. The gathered information will be used to assess an applicant's suitability for employment.

The latest version of the form was released by the VA in November 2016 with copies of the June 2006 edition available until exhausted. An up-to-date VA Form 10 2850C fillable version is available for digital filing and download below or can be found on the VA forms website.

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Approved Exception To SF 171
Use TAB key or Mouse to move between data fields
OMB No. 2900-0205
Estimated burden: 30 minutes
APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
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. OCCUPATION FOR WHICH APPLYING
A
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E
LICENSED PHARMACIST
OTHER (Specify)
REGISTERED RESPIRATORY THERAPIST
PHYSICIAN ASSISTANT
B
F
C
LICENSED PHYSICAL THERAPIST
G
EXPANDED-FUNCTION DENTAL AUXILIARY
D
LICENSED PRACTICAL/VOCATIONAL NURSE
H
OCCUPATIONAL THERAPIST
2. NAME (Last, First, Middle)
3. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
4. PRESENT ADDRESS (Include ZIP Code)
STREET ADDRESS 2
APT. NO.
5. TELEPHONE NUMBER (Include Area Code)
5A. RESlDENCE
5B. BUSINESS
STATE
ZIP CODE
COUNTRY
CITY
6. DATE OF BIRTH
7. PLACE OF BIRTH (City)
STATE
COUNTRY
8. SOCIAL SECURITY NUMBER
9A. CITIZENSHIP
9B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 9B)
10A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
10B. NAME OF OFFICE WHERE FILED
10C. DATE FILED
YES
NO
(If "YES" complete items 10B and 10C)
11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
12. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
13A. DATE FROM
13B. DATE TO
13C. SERIAL OR SERVICE NO.
13D. BRANCH OF SERVICE
13E. TYPE OF DISCHARGE
(Explain on
HONORABLE
OTHER
separate sheet)
II - LICENSURE, DEA CERTIFICATION, REGISTRATION AND CLINICAL PRIVILEGES (As applicable)
14C. CURRENT REGISTRATION
14A. LIST ALL STATES/TERRITORIES IN WHICH
(If "NO" explain on separate sheet)
YOU ARE NOW OR HAVE EVER BEEN LICENSED
14B. LICENSE NO.
14D. EXPIRATION DATE
(If not held now, explain on separate sheet)
YES
NO
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE
15B. DO YOU HAVE PENDING OR HAVE YOU EVER HAD A
15C. HAVE YOU EVER HELD A
IN WHICH YOU RECEIVED A LICENSE
STATE LICENSE TO PRACTICE REVOKED, SUSPENDED,
REGISTRATION TO PRACTICE THAT IS
(If restricted, limited or probational in any State(s),
DENIED, RESTRICTED, LIMITED, OR ISSUED/PLACED ON A
NO LONGER HELD OR CURRENT
explain on separate sheet)
PROBATIONAL STATUS OR VOLUNTARILY RELINQUISHED
(If "YES" explain on
NO
NOT APPLICABLE
NO
(If "YES" explain on separate sheet)
NO
YES
YES
YES
separate sheet)
16A. NAME THE CERTIFYING BODY
16B. DATE OF MOST RECENT
16C. WHAT IS YOUR REGISTRY/
16D. HAS ACTION EVER BEEN TAKEN AGAINST
FOR YOUR HEALTH
REGISTRATION/CERTIFICATION
CERTIFICATION NUMBER
YOUR CERTIFICATION OR REGISTRATION
OCCUPATION
(Give Month and Year)
(If "YES" explain on
NO
YES
separate sheet)
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR
17A. DO YOU CURRENTLY HAVE OR HAVE YOU EVER
17B. NAME OF CURRENT OR MOST RECENT
CLINICAL PRIVILEGES EVER BEEN DENIED,
HAD CLINICAL PRIVILEGES AT ANY HEALTH
INSTITUTION, AGENCY OR
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
CARE INSTITUTION, AGENCY OR ORGANIZATION
ORGANIZATION WHERE HELD
VOLUNTARILY RELINQUISHED
(If "YES" explain on
YES
NO
(If "YES" complete Item 17B)
YES
NO
separate sheet)
III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
I certify that I have verified licensure and registration with State boards, and cited visa or evidence of citizenship.
CERTIFICATION:
Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN CITED IN REGARDS TO:
CERTIFICATION OR REGISTRATION
VISA
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
LICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
19A. SIGNATURE OF AUTHORIZED OFFICIAL
19B. TITLE
19C. DATE (MONTH, DAY, YEAR)
VA FORM
10-2850c
PAGE 1
EXISTING STOCK OF VA FORM 10-2850c, JUN 2006, WILL BE USED.
NOV 2016 (R)
Approved Exception To SF 171
Use TAB key or Mouse to move between data fields
OMB No. 2900-0205
Estimated burden: 30 minutes
APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
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. OCCUPATION FOR WHICH APPLYING
A
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E
LICENSED PHARMACIST
OTHER (Specify)
REGISTERED RESPIRATORY THERAPIST
PHYSICIAN ASSISTANT
B
F
C
LICENSED PHYSICAL THERAPIST
G
EXPANDED-FUNCTION DENTAL AUXILIARY
D
LICENSED PRACTICAL/VOCATIONAL NURSE
H
OCCUPATIONAL THERAPIST
2. NAME (Last, First, Middle)
3. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
4. PRESENT ADDRESS (Include ZIP Code)
STREET ADDRESS 2
APT. NO.
5. TELEPHONE NUMBER (Include Area Code)
5A. RESlDENCE
5B. BUSINESS
STATE
ZIP CODE
COUNTRY
CITY
6. DATE OF BIRTH
7. PLACE OF BIRTH (City)
STATE
COUNTRY
8. SOCIAL SECURITY NUMBER
9A. CITIZENSHIP
9B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 9B)
10A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
10B. NAME OF OFFICE WHERE FILED
10C. DATE FILED
YES
NO
(If "YES" complete items 10B and 10C)
11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
12. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
13A. DATE FROM
13B. DATE TO
13C. SERIAL OR SERVICE NO.
13D. BRANCH OF SERVICE
13E. TYPE OF DISCHARGE
(Explain on
HONORABLE
OTHER
separate sheet)
II - LICENSURE, DEA CERTIFICATION, REGISTRATION AND CLINICAL PRIVILEGES (As applicable)
14C. CURRENT REGISTRATION
14A. LIST ALL STATES/TERRITORIES IN WHICH
(If "NO" explain on separate sheet)
YOU ARE NOW OR HAVE EVER BEEN LICENSED
14B. LICENSE NO.
14D. EXPIRATION DATE
(If not held now, explain on separate sheet)
YES
NO
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE
15B. DO YOU HAVE PENDING OR HAVE YOU EVER HAD A
15C. HAVE YOU EVER HELD A
IN WHICH YOU RECEIVED A LICENSE
STATE LICENSE TO PRACTICE REVOKED, SUSPENDED,
REGISTRATION TO PRACTICE THAT IS
(If restricted, limited or probational in any State(s),
DENIED, RESTRICTED, LIMITED, OR ISSUED/PLACED ON A
NO LONGER HELD OR CURRENT
explain on separate sheet)
PROBATIONAL STATUS OR VOLUNTARILY RELINQUISHED
(If "YES" explain on
NO
NOT APPLICABLE
NO
(If "YES" explain on separate sheet)
NO
YES
YES
YES
separate sheet)
16A. NAME THE CERTIFYING BODY
16B. DATE OF MOST RECENT
16C. WHAT IS YOUR REGISTRY/
16D. HAS ACTION EVER BEEN TAKEN AGAINST
FOR YOUR HEALTH
REGISTRATION/CERTIFICATION
CERTIFICATION NUMBER
YOUR CERTIFICATION OR REGISTRATION
OCCUPATION
(Give Month and Year)
(If "YES" explain on
NO
YES
separate sheet)
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR
17A. DO YOU CURRENTLY HAVE OR HAVE YOU EVER
17B. NAME OF CURRENT OR MOST RECENT
CLINICAL PRIVILEGES EVER BEEN DENIED,
HAD CLINICAL PRIVILEGES AT ANY HEALTH
INSTITUTION, AGENCY OR
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
CARE INSTITUTION, AGENCY OR ORGANIZATION
ORGANIZATION WHERE HELD
VOLUNTARILY RELINQUISHED
(If "YES" explain on
YES
NO
(If "YES" complete Item 17B)
YES
NO
separate sheet)
III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
I certify that I have verified licensure and registration with State boards, and cited visa or evidence of citizenship.
CERTIFICATION:
Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN CITED IN REGARDS TO:
CERTIFICATION OR REGISTRATION
VISA
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
LICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
19A. SIGNATURE OF AUTHORIZED OFFICIAL
19B. TITLE
19C. DATE (MONTH, DAY, YEAR)
VA FORM
10-2850c
PAGE 1
EXISTING STOCK OF VA FORM 10-2850c, JUN 2006, WILL BE USED.
NOV 2016 (R)
IV - LIABILITY INSURANCE (As applicable)
20A. PRESENT LIABILITY
20B. DATE COVERAGE
21. HAS ANY CARRIER EVER
20C. NAMES OF PRIOR CARRIERS
20D. DATE OF COVERAGE
INSURANCE CARRIER
BEGAN
CANCELLED, DENIED OR
TO
FROM
REFUSED TO RENEW YOUR
INSURANCE
NO
YES
(If "YES" explain on separate sheet)
V - QUALIFICATIONS
BASIC ALLIED HEALTH EDUCATION (Continue on separate sheet, if necessary)
22C. LENGTH OF
22D. DATE
22E. DIPLOMA OR
22A. NAME OF SCHOOL
22B. ADDRESS (City, State and ZIP Code)
PROGRAM
COMPLETED
DEGREE RECEIVED
ADDITIONAL EDUCATION (Continue on separate sheet, if necessary)
23D. DATE
23E.
23F.
23A. NAME OF SCHOOL
23B. ADDRESS (City, State and ZIP Code)
23C. MAJOR
CREDITS
DEGREE
COMPLETED
Vl - PROFESSIONAL EXPERIENCE
24C. POSITION (Where
26F. DATES EMPLOYED
26D.
26E.
PART-TIME
applicable, also specify
24A. EMPLOYER
24B. ADDRESS (City, State and ZIP Code)
FULL-
AVERAGE
HOURS
whether General
TIME
PER WEEK
FROM
TO
Practitioner or Specialist)
Vll - GENERAL INFORMATION
25. NAMES UNDER WHICH YOU WERE EMPLOYED, IF DIFFERENT FROM NAME GIVEN IN ITEM 1.
26. LIST ALL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS, FELLOWSHIPS (If additional space is required, attach separate sheet).
VlIl - REFERENCES
27. REFERENCES: List at least four persons 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
qualifications during the past five years.
27A. NAME
27B. ADDRESS (Number, Street, City, State and ZIP Code)
27C. AREA CODE/PHONE NO.
27D. BUSINESS OR OCCUPATION
VA FORM
10-2850c
PAGE 2
NOV 2016 (R)
REFERENCES (Continued)
27A. NAME
27B. ADDRESS (Number, Street, City, State and ZIP Code)
27C. AREA CODE/PHONE NO.
27D. BUSINESS OR OCCUPATION
ITEM NO.
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET
YES
NO
Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based
28.
upon military, Federal civilian, or District of Columbia service?
Does the Department of Veterans Affairs employ any relative of yours (by blood or marriage)? If "YES" give separately such
29.
relative's (1) full name; (2) relationship; (3) VA position and employment location.
ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE 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.)
30.
(As a provider of health care services, the VA has an obligation to exercise reasonable care in determining that applicants are
properly qualified. It is recognized that many allegations of malpractice are proven groundless. Any conclusion concerning
your answer as it relates to your 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 33, 34 or 35 is "YES" give for each offense: (1) date;
(2) charge; (3) place; (4) court and (5) action taken. When answering item 33 or 34, 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?
31.
Within the last five years have you resigned or retired from a position after being notified you would be disciplined or
32.
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
33.
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
34.
now under charges for any offense against the law not included in 33 above?
While in the military service were you ever convicted by a general court-martial?
35.
If you were in the military service in one of these health occupations, did you ever receive a non-judicial punishment
36.
(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.)
37.
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.
IX - 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 STATEMENTS ARE
CERTIFICATION:
TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.
38A. SIGNATURE OF APPLICANT
38B. DATE (Month, Day,Year)
VA FORM
10-2850c
PAGE 3
NOV 2016 (R)
AUTHORIZATION FOR RELEASE OF INFORMATION
In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and suitability for
employment, I:
Authorize VA to make inquiries concerning such information about me to my previous employer(s), current employer, educational institutions, State
Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and to State
licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of any other
appropriate sources to whom VA may be referred by those contacted or deemed appropriate;
Authorize release of such information and copies of related records and/or documents to VA officials;
Release from liability all those who provide information to VA in good faith and without malice in response to such inquiries; and
Authorize VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable VA to
make such inquiries.
SIGNATURE
DATE
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of
section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information
unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This
includes the time it will take to read instructions, gather the necessary facts and fill out the form.
AUTHORITY: The information requested on the attached application form and Authorization for Release of Information is solicited under Title 38, United
States Code, Chapters 73 and 74.
PURPOSES AND USES: The information requested on the application is collected primarily to determine your qualifications and suitability for
employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel
administration processes carried out in accordance with established regulations and the published notice of the system of records "Applicants for
Employment under Title 38, U.S.C.-VA" (02VA135)
ROUTINE USES: Information on the form or the form itself may be released without your prior consent outside the VA to another Federal, State or local
agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, and/or
appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically verify,
evaluate and update your clinical privileges and licensure status, to report apparent or potential violations of law, to provide statistical data upon proper
request, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may also be released without
your prior consent to Federal agencies, State licensing boards, or similar boards or entities, in connection with the VA's reporting of information concerning
your separation or resignation as a professional staff member under circumstances which raise serious concerns about your professional competence.
Information concerning payments related to malpractice claims and adverse actions which affect clinical privileges also may be released to State licensing
boards and the National Practitioner Data Bank. The information you supply may be verified through a computer matching program at any time.
EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Disclosure of the other information is
voluntary; however, failure to provide this information may delay or make impossible the proper application of Civil Service rules and regulations and VA
personnel policies and thus may prevent you from obtaining employment, employees benefits, or other entitlements.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)
Disclosure of your SSN (social security number) is mandatory to obtain the employment and related benefits that you are seeking. Solicitation of the SSN is
authorized under the provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from
the time of application through retirement. It will be used primarily to identify your records. The SSN also will be used by Federal agencies in connection
with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information
gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established
regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of
personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants
who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
VA FORM
10-2850c
PAGE 4
NOV 2016 (R)

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VA Form 10-2850C Instructions

The form is distributed without any filing guidelines. Detailed step-by-step filing instructions can be found below.

How to Fill Out VA Form 10-2850C?

  1. The first box of the form contains the occupations available for application. The applicant must select "Other" and identify the occupation if the desired position is not featured on the list.
  2. Boxes 2 through 12 should contain the applicant's personal information. This includes their name, address, date, and place of birth, SSN and citizenship information. Box 3 is filled in if the candidate is applying for a certain specialty.
  3. If the applicant had ever filed the application before, this should be specified in Boxes 10a through 10c.
  4. Section I describes the applicant's military service. The individual must specify whether or not they have served on active military duty. If the answer is negative, the section should be left blank.
  5. Box 13e requires the type of discharge. Other-than-honorable discharge requires a further explanation on a separate sheet of paper that must be attached to the form.
  6. Section II pertains to licensure: DEA certification, registration, and clinical privileges - if applicable. The applicant has to provide full information on their licenses: where and when the license was obtained, the number of licenses, the current registration, and an expiration date.
  7. Boxes 15a through 15c require information regarding any problems with the license: whether it was restricted, suspended or denied in any state. Boxes 16a through 16d require the certifying body for the current occupation, the most recent certification date, and its number, the specification, and whether or not any action was taken against certification or registration. Additional sheets may be used to include all the certifications or to explain the information given.
  8. Section III is to be completed by the reviewing agency.
  9. Section IV provides information about liability insurance. It is filled as stated only if applicable.
  10. An applicant's qualifications must be described in Section V. Boxes 22a through 22e specify the name of schools, their address (including ZIP code), the program length, the date of completing the program, and the documents that verify attendance (a diploma or the awarded degree).
  11. Section VI describes the previous professional experience. Column 24a is for listing the names of previous employers, Column 24b is for providing their addresses and Column Box 24c is for specifying the occupation in every case.
  12. The form of contract - either full or part-time - is identified in Column 26d. If the applicant was a part-time employee, the average number of hours per week is given in Column 26e. Column 26f indicates the period of employment for each place of occupation.
  13. Section VII provides space for any additional information. Box 25 is filed by applicants employed under any names other than the one specified in Box 2. Any publications, awards, grants or fellowships should be listed in Box 26.
  14. The qualifications for every candidate must be provided by qualified professionals not related to the applicant by blood or marriage. These people should be listed as references in Section VIII, Boxes 27a through 17d.
  15. Boxes 28 through 37 contain yes-or-no questions that need to be answered by the applicant. These include questions about any previous convictions or imprisonment, being discharged from a position and having Federal debts.
  16. The applicant must certify the provided information by signing the form in Box 38 and once again in the space provided on the fourth page of the form.

VA Form 10-2850C FAQ

How do I save VA Form 10-2850C in a fillable format?

You must have the latest Adobe Acrobat Reader installed on your computer or mobile device in order to save the data within the PDF.

How to electronically sign VA Form 10-2850C?

Signing the form is no different from signing other e-fillable documents. There are several options for creating your own electronic signature:

  1. Open the file you want to sign in Adobe Reader and select "Add Signature"
  2. Select "Type" to type your name and have it converted to a signature.
  3. Select "Draw" and draw your signature using your mouse, a touch screen or a stylus.
  4. Select "Image" to upload a scanned and cropped picture of your actual signature.

VA 10-2850C Related Forms

There are several forms related to the application and intended for specific occupations.

  1. VA Form 10-2850, Application for Physicians, Dentists, Podiatrists, Optometrists and Chiropractors is filed by specialists applying to one of these positions in Veterans Health Administration to prove their eligibility for appointment.
  2. VA Form 10-2850A, Application for Nurses and Nurse Anesthetists is used by the applicants to describe their education and professional experience and provide professional references to prove their eligibility for appointment.
  3. VA Form 10-2850D, Application for Health Professions Trainee is filed by individuals applying for the VA clinical training program. The data provided in the form may also be used for making pay and benefit determinations or personnel administration if an applicant is employed by the VA.

The series also used to include the now obsolete VA Form 10-2850B, Application for Residents.

Video Instructions for VA Form 10-2850c

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