Enclosure (3) to COMDTINST 6010.2B
REQUIRED APPLICATION INFORMATION for
AUXILIARY HEALTH CARE ACTIVITIES
1.
Name:
2.
Address:
3.
Phone number:
Auxiliary Member Number, District, Division, Flotilla:
4.
5.
E-mail address:
6.
SSN:
7.
DOB:
8.
Copy of the following credentialing documentation:
a. Active state licenses or state or federal registry certificate (with number and expiration date)
b. Healthcare Provider Basic Life Support Certification (CPR) card with expiration date
c. Diploma indicating school and date of graduation from medical/dental/professional school
d. Controlled Substance Registration Certificates (DEA) (if applicable)
e. Two letters of reference discussing moral character and medical/dental/professional
qualifications
f. Curriculum Vitae (resume)
g. Board certification, if attained
h. Certificate of internship, residency completed (if applicable)
i. Most recent or current clinical privileges from hospitals/services where privileged that
enumerate the procedures that you are authorized/qualified to perform (if applicable)
Privacy Act Statement for Individual Credentials File (ICF) Requests (Enclosure (3))
9.
10. The clinic, station, or unit where desiring to volunteer:
a. Name of Senior Medical Officer (SMO), Senior Dental Officer (SDO), Chief, Health Services
Division, Officer in Charge (OINC), or Commanding Officer (CO)
b. Address of clinic, station, or unit
c. Phone number
d. E-mail address
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