VA Form 10-2850a Application for Nurses and Nurse Anesthetists

How to Fill Out VA Form 10-2850A?

All the answers in VA Form 10-2850A should be typed or printed in ink. If the space provided is not enough, it is allowed to attach separate sheets. It takes about 30 minutes to review the instructions, find the necessary information, and complete the form. By signing the application, you certify that the indicated information is true, correct, and complete. Providing false statements can result in your application getting rejection, or, in some cases, result in fines or imprisonment.

VA Form 10-2850A instructions are as follows:

1. Select the type of application in Item 2.
2. Item 1 and Items 3 through 8B require your detailed personal information including name, address, phone number, full address, residence and business phone number, date and place of birth, Social Security Number (SSN), and citizenship.
3. If you have ever filed the application for appointment in the VA, this data should be indicated in Items 9A through 9C.
4. The time when the inquiry of the present employer may be made and available for employment date should be provided in Items 10 and 11 correspondingly.
5. Items 12A through 12E require data about active military duty. If the discharge was other than honorable, you must comment on it on a separate sheet and attach it to this document.
6. Section II requires information about all your registrations as a nurse and clinical privileges. It contains a table for listing all states and territories you have ever been registered as a nurse and a list of Yes/No questions you need to answer.
7. Section III must be completed by nurse anesthetists only. It requires details about their certification.
8. Section IV is to be filled out and signed by the facility director or designee.
9. Indicate the details about current professional liability insurance in Section V.
10. Section VI requires data about your basic nursing education and additional education.
11. You can describe your nursing experience in Section VII.
12. Section VIII is for general information. List all your professional publications, research grants, and awards, as well as names under which you were employed (if different from indicated in Section I).
13. You can enumerate individuals who have been in the position to judge your professional qualification during the past 5 years in Section IX.
14. Items 30 through 39 are Yes/No questions. All positive answers require further explanation (can be done on a separate sheet and attached to the form).
15. The last section should contain your signature and date. After completing the application, you must also complete and sign the "Authorization for Release of Information" on the fourth page of the document.

Not what you were looking for? Check out these related forms:

• VA Form 10-2850, Application for Physicians, Dentists, Podiatrists, Optometrists & Chiropractors;
• VA Form 10-2850C, Application for Associated Health Occupations;
• VA Form 10-2850D, Application for Health Professions Trainees.