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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