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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.)

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 12

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