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US Coast Guard Command Instructions
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Attestation
Coast Guard Auxiliarists Support to Coast Guard Health Care Facilities
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Enclosure
(6)
to
COMDTINST
6010.2B
Verification
Conditions and
Release
of
Information
1.
All statements or
information
provided
on
this
application
are
subject
to
primary
source
verification
and
you
are
authorizing
the
contracting
Verification
Agency,
Armed
Forces
Institute
of
Pathology
(AFIP),
on
behalf
of
the
U.S.
Government
to
obtain
and
verify
as
much
of
the
following
information
as
may
be
necessary
to
arrive
at an
employment
decision.
a.
Official
college
transcripts.
b.
Letters
of
Recommendation
to
include
scope
of
practice
and
malpractice
events
c.
Professional
and
specialty
certificates
and
licenses(s).
d.
Statement
from
ALL
malpractice
insurance
carriers
(including
umbrella
insurance
coverage
for
residency
and
internship)
dating
back 10 years
indicating
nature
of
applicant's
coverage;
whether
applicant's
policy
was/will
be
renewed;
whether
all
malpractice
claims
were
filed
against
the
applicant
under
the
policy,
and
the
status of
these
claims.
e.
Professional
Employment
History.
2.
All
false
or
misleading
information
on
this
applicant,
or
withholding
of
pertinent
information,
will
result
in a
delay
of
the
certification
procedure
and will
additionally
affect
the
review
process.
3.
With
your
signature
below,
you
are
indicating
that
you
have
read
and
understand
the
above
statements
concerning
the
verification
process.
I
consent
to the
release,
by any
person
to
AFIP,
of
all
information
that
may
be
relevant
to an
evaluation
of my
qualifications,
including
information
about
disciplinary
actions
or
other
confidential
or
privileged
information.
I
release
from
any and
all
liability
anyone
providing
this
information
in
good
faith
and
without
malice.
This
information
is accurate and
true
to the
best
of my
knowledge.
_____________________________________________
Signature
Date
_____________________________________________
Applicant's
name
(Print)
_____________________________________________
Witness
Date
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