Application for Associated Health OccupationsApplication for Associated Health OccupationsApplication for Associated Health Occupations
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Approved Exception To SF 171
OMB No. 2900-0205
Estimated burden: 30 minutes

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APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.

INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Affairs to
determine your eligibility for appointment in Veterans Health Administration.
Type, or print in ink. If additional space is required, please attach a separate sheet and refer to items being answered by number.
1. OCCUPATION FOR WHICH APPLYING
A

CERTIFIED RESPIRATORY THERAPY TECHNICIAN

E

LICENSED PHARMACIST

B

REGISTERED RESPIRATORY THERAPIST

F

PHYSICIAN ASSISTANT

C

LICENSED PHYSICAL THERAPIST

G

EXPANDED-FUNCTION DENTAL AUXILIARY

D

LICENSED PRACTICAL/VOCATIONAL NURSE

H

OCCUPATIONAL THERAPIST

2. NAME (Last, First, Middle)

OTHER (Specify)

3. APP