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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.)

3.Medical/Professional Education:  

Please provide the following information for your medical school of graduation.

Name of School

Degree Received

Dates of Attendance  (List Mo/Yr)

From:  

To:  

Street Address

Phone # (if known)

Fax # (if known)

Graduation Date

(   )    -

(   )    -

City

State

Country

Zip Code

NOTE:The remainder of Section 3 (Medical/Professional Education) and Section 4 (Professional Training) have been intentionally omitted.  If additional formal education/training has been obtained since the date of last credentialing, please complete Sections 3 and 4 from the Credentialing application as appropriate and attach.

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 6

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