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RGANIZATION WHERE HELD NO YES (If "YES", explain on seperate sheet) VA FORM JUN 2006 (R) CURRENT REGISTRATION (All States) 10-2850 NO III - THIS SECTION TO BE COMPLETED BY THE CHIEF OF STAFF I certify that I have verified licensure and registration with State boards, and sighted visa or evidence of citizenship. Board certification has been verified (if appropriate). 18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO: FULL LICENSURE 17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR CLINICAL PRIVILEGE.

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