Duke Residents

Items listed below must be received by the Durham VAHCS NLT April 30, 2021:   

Mailing Address:

Durham VA Medical Center
Duke Residency
Durham VA Medical Center [insert mail code from Point of Contact document]
Attn: [insert name of DVAHCS point of contact from the Point of Contact document]
508 Fulton Street
Durham, North Carolina 27705 

(Please download each document to your computer in order to edit and input your information.)

VA Form 10-2850D Application for Health Professions Trainee Dated Nov 2011

INSTRUCTIONS FOR COMPLETING THE VA FORM 10-2850D

Page 1
1 A. Name – (Provide FIRST, FULL MIDDLE, & LAST NAME). If you don’t have a middle name, indicate “No Middle Name”.  If you have only initials in your name, provide them and indicate “Initial only”. 

1. Complete maiden names, nick names, other spellings, or name changes
2. Address - Complete address to include zip code

3A &3B. Telephone – Telephone number to include area code for morning and evening

4. Social Security # - Complete 9-digit social security number

5A. Primary Email Address – Best email address to reach you

5B.  Alternate Email Address -

6. Date of Birth – Month, Day, and Year of birth
7. Training Facility (City, State) – Durham, NC

7B& 7C – check the unknown box

8A – Are you now in the U.S. Military – select the response that applies to you

8B.  Are you in the Reserves of National Guard? – select the response that applies to you

8C. Branch of Service – enter as appropriate or enter N/A or None

8D. Start Date of your Degree, Month and Year

9A. Enter citizenship status

9B. Enter your country of citizenship

Complete items 10A, 10B, 10C and 10D only if you are not a US Citizen

Page 2

(Please provide your complete name & SSN at top of the page)

Item V

Current Clinical License or Certifications – Complete all fields, if none, N/A or None

Item VI

Previous Clinical License or Certifications - Complete all fields, if none, N/A or None

15 – enter your National Provider Identifier (NPI)

16 – complete

17 – complete

Item VII – Education and Training

18 A – Enter all schools after high school in chronological order

18B – Enter address of schools

18C – Enter start date for program

18D – completion date

18E – Diploma earned

18F – Field of Study

Item VIII

International Graduates – If you are an international student, complete all fields

Item IX

Internship, Residency, and Fellowship – If apply, complete all fields with full name of school and complete physical address WITH City, State and Zip or N/A or None

Page 3

(Please provide your complete name & SSN at top of Pages 2-4. Sign pages 3 & 4.

Item X

Respond to questions 21, 22 & 23

Item XI

Additional space for previous responses

Sign and date page 3 at the bottom of the form

Page 4

(Please provide your complete name & SSN at top of Pages 2-4. Sign pages 3 & 4)

Authorization for Release of Information – Read and Check all boxes, date, sign and read privacy notice Name and Social Security number should be on top of every page where specified

Sign and date page 4

 

Form (OF) 306, Declaration for Federal Employment

Instructions for completion of the OF-306:

• (Provide FIRST NAME, FULL MIDDLE NAME, & LAST NAME). If you don’t have a middle name, indicate “No Middle Name”.  If you have only initials in your name, provide them and indicate “Initial only”
• Social security number

• Place of birth
• U.S. citizenship status
• Date of birth
• Other names ever used- Complete maiden names, nick names, other spellings, or name changes
• Phone numbers
• Selective service registration
• Background information about convictions, firings, delinquent federal debt
• Whether your relatives work for the agency or government organization to which you are submitting this form
• Whether you receive or have ever applied for retirement pay, pension, or other retired pay based on military, federal civilian or District of Columbia Government service
• Signature (Sign as applicant)
• Date
• Date you left last federal job if any
• Whether you waived basic life insurance or any type of optional life insurance when you last worked for the federal government, whether you later cancelled that waiver

Courtesy Fingerprints

Courtesy Fingerprinting: You must contact a nearby VA, to begin the fingerprint clearance process prior to arriving in Durham (Present the DVAMC Appointment letter and the Courtesy fingerprints document to your Local VA Facility.  Locations for courtesy fingerprints can be found at  https://www.oit.va.gov/programs/piv/locations.cfm 

Advise your DVAHCS POC when and where courtesy prints were taken. Do not hesitate to complete this requirement

Mandatory Training

VHA Mandatory Training for Trainees (MTT): must be completed prior to submitting paperwork   Go to TMS website-Self register and complete MTT. You need the following information to complete self-registration:
VA Location: DUR
 
Provide a copy of your course completion to your DVAHCS POC  when you submit your paperwork

*Trainees who previously had TMS accounts: Change your email accounts in TMS to ensure you can access the email account listed.  If you previously had a TMS account and can no longer access it, please send an email to VHADURTMSDOMAINMANAGERS@va.gov requesting assistance

Current PIV Badge Holders

If you have a PIV badge from another VA facility, please advise your DVAHCS POC. 

Personal Identity Verification (PIV) (Submit a copy of your social security card and driver's license, state ID or VISA to your DVAHCS POC NLT April 30, 2021). Please notify POC of any changes to Driver’s License, State ID or VISA prior to orientation.  

 Lost, Stolen, Destroyed, or Damaged PIV Badge (If previously issued a PIV badge that has been lost, stolen, or destroyed, please fill out the PIV Memo through your signature line. Return document your DVAHCS POC) 

NPI Number

NPI Number (Include your NPI number on your VA Form 10-2850 and print page with NPI Number and send page to your DVAHCS POC)