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State of West Virginia

Recredentialing Form

Responses must be legible.  Any response, which cannot be completed in the space provided, may be included on supplementary sheets of paper and attached.  DO NOT LEAVE ANY FIELDS BLANK. If an item is not applicable, indicate N/A.  Please note you will be held responsible for all information or omissions in this application, regardless of whether such statements were prepared by you, an employee, agent or representative.  For time gaps greater than three (3) months provide information in Section 11.   After completion of the application, you may photocopy and then submit with a signed attestation to each entity to which you wish to apply.

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.)

1.Applicant Information (Entire section must be completed)

Last Name

(as shown on state license)

First Name

Middle Name

Maiden Name

Suffix

(e.g., Jr., Sr., etc.)

Degree (e.g., MD, DO, DDS, DPM, PA-C, RN)

Other Name(s) Also Known By

Name(s)

Name:  

Name:  

Date Name Used

From:

To:  

From:  

To:  

Area(s) of Specialty (please be specific and list any primary focus)

Specialty:  

Sub-specialty:  

Current Home Address

City

State

Zip Code

Home Telephone

Is this # unlisted?

Home Fax

(    )  -

Yes No

(    )      -

If citizenship status or VISA status has changed, please indicate below

and attach an explanation as well as pertinent documentation.

Citizenship/VISA status has changed.

Language(s) Spoken (other than English)

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 2

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