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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

Telephone Number

Fax Number

() -

() -

Department/Service

Department Chair’s Name

Staff Status

# Admits/Month

Percent of time spent at facility

Restricted?

Dates of Affiliation (Mo/Yr)

Yes No

If yes, explain:  

From: To:

Reason for leaving, if applicable

10.Work History/Experience:

List in chronological order (beginning with current) all current and previous professional work history SINCE THE LAST CREDENTIALING DATE, including Military Service.  You must explain gaps greater than three (3) months in Section 11.  (If additional space is needed, please photocopy this page and attach.)

Practice/Employer

Contact Name

Street Address

City

State

Zip

Telephone Number

Fax Number (if known)

(   )    -

(   )    -

Dates of Employment (Month/Year)

Job Title or Type of Work Performed

From: To:

Reason for leaving, if applicable

Practice/Employer

Contact Name

Street Address

City

State

Zip

Telephone Number

Fax Number (if known)

(   )    -

(   )    -

Dates of Employment (Month/Year)

Job Title or Type of Work Performed

From: To:

Reason for leaving, if applicable

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 11

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