North Florida-South Georgia Veterans Health System ...



Date of Application____________________Personal Last Name: ___________________________ First Name: ______________________ Middle Initial: ____Current Address:Permanent Address:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date of Birth: ___________________Email Address: _______________________________Telephone Number: Home: ______________________Cell: ___________________________ Education and TrainingPA program Attended /Attending: ________________________________________________________Graduation: Month/Year _______/_______ Graduate College: ________________________________________________________________Degree Obtained: ______________________ Major: __________________ Graduation Year_________Undergraduate College: ________________________________________________________________Degree Obtained: ______________________ Major: __________________ Graduation Year_________NCCPA Certified:YesNo (If No, Date scheduled to take exam :________________)Date Certified: _______________Certification Number: ____________________Are you licensed as a PA:Yes (complete information below)NoPendingState Licensed/Number: _________/_________Expiration of State License: ________________Have you ever been disciplined for academic performance or professional conduct by ANY institution or training program?Yes No Have you ever been charged or convicted of a felony? Yes NoHave you ever been charged or convicted of a misdemeanor, other than a minor traffic offense? Yes NoHave you ever had a professional license revoked or suspended? Yes NoHave you ever been denied hospital privileges or had your privileges restricted? Yes No Have you been denied membership in any professional organization? Yes NoIf you answered YES to any of the above questions, please submit along with the application a single page explanation of the events and the resulting decisions.Letters of RecommendationPlease list 3 persons who will be sending a letter of recommendation on your behalf. (One letter must be from your program director). NameTitleDaytime Phone NumberNameTitleDaytime Phone NumberName Title Daytime Phone NumberPlease be sure the following are included with the application:Personal Statement: A one-page statement explaining why you are applying to this post-graduate program and how you believe the training will benefit you in the future. Proof of NCCPA Certification (or documentation of scheduled date to take the exam)Copy of transcripts from institution granting PA degree should be forwarded to the Postgraduate Program OfficesCopies of BLS and ACLS Certifications (if completed)I certify that the information in this application is complete and correct to the best of my knowledge. ____________________________________________________________________________SignatureDate ................
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