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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES ----------------0--------------- DEPARTMENT OF HEALTH “Wellness is Our Way of Life” APPLICATION FOR HEALTH-RELATED OCCUPATION BUSINESS LICENSE (PLEASE TYPE ONLY) DATE: _____________ NAME: _____________________________ ___________________ _______________________ _________ first middle last suffix DATE OF BIRTH:(MM/DD/YYYY) ____ / _____/ __________ SOCIAL SECURITY # (LAST FOUR DIGITS): ____________________ MAILING ADDRESS: __________________________________________CITY________________STATE____ZIP CODE_______ RESIDENTIAL ADDRESS:________________________________________CITY________________STATE____ZIP CODE_______ INTENDED NAME /PLACE OF BUSINESS: _______________________________________________________________________ OCCUPATION / TYPE OF BUSINESS:________________________________________ DCLA CONTROL# ___________________ PHYSICAL BUSINESS ADDRESS: _________________________________CITY_________________STATE____ZIP CODE_______ EMAIL ADDRESS: _____________________________________________ MOBILE PHONE NUMBER: _________________________ WORK PHONE NUMBER: _________________________ Mail to: Professional Licensure & Health Planning P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: (340) 773-1561 Ext. 4431 Updated January 29, 2024. Failure to furnish all required documents will delay processing. pg. 1 EDUCATION/TRAINING SCHOOL NAME / ADDRESS DATES MM/YYYY GRAD. Y/N DEGREE / #HRS CONTACT NAME / TELEPHONE # START Y - N DEGREE TYPE FINISH #HOURS START Y - N DEGREE TYPE FINISH #HOURS START Y - N DEGREE TYPE FINISH #HOURS START Y - N DEGREE TYPE FINISH #HOURS PLEASE COPY AND ADD BLANK SHEET(S) IF NECESSARY. STATE /PROFESSIONAL/CERTIFICATIONS STATE / ORGANIZATION LICENSE# / TYPE EXPIRATION CONTACT NAME / TELEPHONE / ADDRESS Mail to: Professional Licensure & Health Planning P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: (340) 773-1561 Ext. 4431 Updated January 29, 2024. Failure to furnish all required documents will delay processing. pg. 2 WORK EXPERIENCE EMPLOYER'S NAME & ADDRESS DATES MM/YYYY POSITION CONTACT NAME / TELEPHONE # START FINISH START FINISH START FINISH START FINISH COPY AND ADD ADDITIONAL SHEETS IF NECESSARY. Has applicant ever undergone disciplinary hearing? ❑YES ❑NO If (YES), Please Explain: Has the applicant been convicted of felony or misdemeanor? ❑YES ❑NO If (YES), Please Explain and attach a copy of disposition. Mail to: Professional Licensure & Health Planning P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: (340) 773-1561 Ext. 4431 Updated January 29, 2024. Failure to furnish all required documents will delay processing. pg. 3 Has there been a malpractice settlement? ❑YES ❑NO If (YES) How many? ______ When was latest? ______________________________ For what? _____________________________________ What was the award? ____________________________________ What was the settlement? _____________________________ I hereby affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct. I further wave, for process of this application, any confidentiality provisions concerning the information required to be provided to this application. _________________________________ ___________ _________________________________ __________ APPLICANT SIGNATURE DATE WITNESS SIGNATURE DATE Subscribed and sworn to before me this _____ day of ______________________ 20 _____ _____________________________ Notary Public _____________________ My Commission Expires Mail to: Professional Licensure & Health Planning P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: (340) 773-1561 Ext. 4431 Updated January 29, 2024. Failure to furnish all required documents will delay processing. pg. 4 BE SURE TO ATTACH: (CHECK LIST) 1. ❑ LEGIBLE COPY OF GOVERNMENT ISSUED IDENTIFICATION; 2. ❑ HAVE OFFICIAL SCHOOL TRANSCRIPT(S) FORWARDED TO PROFESSINAL LICENSURE & HEALTH PLANNING OFFICE; 3. ❑ HAVE OFFICIAL STATE LICENSE VERICATION(S) FROM ALL STATES EVER LICENSED FORWARDED TO BOARD OFFICE; 4. ❑ INCLUDE DETAILED NARRATIVE DESCRIBING PROPOSED BUSINESS (SERVICE, LOCATION, MOUs, CONTRACTS, ETC...); 5. ❑ COPY OF CREDENTIALS; 6. ❑ NOTARIZED NON-ADDICTION LETTER; 7. ❑ TWO (2) CURRENT, ORIGINAL SIGNED PROFESSIONAL RECOMMENDATION FORMS (FROM COLLEAGUES OR LICENSED PROFESSIONALS FAMILIAR WITH YOUR CLINICAL SKILLS); 8. ❑ COPY OF VI POLICE RECORD; AND IF LIVING IN THE USVI LESS THAN 2 YEARS, YOU ALSO NEED TO SUBMIT A POLICE RECORD FROM LAST CITY/STATE OR COUNTRY OF RESIDENCE PRIOR TO MOVING TO THE USVI; 9. ❑ SUBMIT PROOF OF NATIONAL CERTIFICATION IN YOUR RESPECTIVE OCCUPATION; 10. ❑ PROOF OF LIABILITY INSURANCE; 11. ❑ COMPLETE NOTARIZED AUTHORIZATION OF RELEASE FORM; 12. ❑ SUBMIT COPIES OF DIPLOMAS, CERTIFICATIONS, LICENSES, ETC...; 13. ❑ SUBMIT A CURRENT (DATED WITHIN 6 MONTHS OF VI APPLICATION) NATIONAL PRACTITIONER DATA BANK SELF-QUERY. A. VISIT HTTPS://WWW.NPDB.HRSA.GOV/EXT/SELFQUERY/SQHOME.JSP AND BEGIN THE PROCESS FOR THE SELF-QUERY. FOLLOW ALL INSTRUCTIONS GIVEN. B. AFTER YOUR SELF-QUERY HAS BEEN PROCESSED BY THE NPDB, THEY WILL SEND THE SELF-QUERY REPORT DIRECTLY TO YOU. C. YOU MUST FIRST OPEN THIS REPORT TO MAKE SURE THAT THE RESULTS WERE NOT REJECTED, AND ALL INFORMATION SUBMITTED IS CORRECT. D. SEND ALL PARTS OF THE SELF-QUERY REPORT DIRECTLY TO OUR OFFICE WITH YOUR APPLICATION. E. FOR NPDB QUESTIONS OR ASSISTANCE, CALL 800-767-6732 OR EMAIL HELP@NPDB.HRSA.GOV; AND 14. ❑ THE APPLICATION MUST BE NOTARIZED. BE SURE TO: 1. KEEP A COPY OF THE APPLICATION FOR YOUR FILE. (DO NOT SEND ANY OFFICIAL ORIGINAL DOCUMENTS). 2. MAIL THE ORIGINAL APPLICATION TO THE ADDRESS BELOW (FAXED AND EMAILED APPLICATIONS ARE NOT ACCEPTED) Mail to: Professional Licensure & Health Planning P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: (340) 773-1561 Ext. 4431 Updated January 29, 2024. Failure to furnish all required documents will delay processing. pg.5 AUTHORIZATION FOR RELEASE OF INFORMATION In connection with my application for Allied Health clearance in the United States Virgin Islands, I hereby authorize and consent to the release of any and all information requested by the Virgin Islands Department of Health's Office of Professional Licensure and Health Planning (PLHP). Additionally, I release from liability any hospital or agency releasing such information to PLHP in good faith.  Make inquiries concerning such information about me to my employer (past and present), hospital(s), or institution(s), my reference(s), all governmental agencies and instrumentalities (local, state, federal, or foreign);  Authorize the release of such information and copies of related records and documents to PLHP;  Authorize PLHP to disclose to such persons, employers, hospitals, institutions, organizations, references, governmental agencies and instrumentalities identifying and other information about me sufficient to enable the Board to make such inquiries;  Release from liability all those who provide information to the Virgin Islands Department of Health or PLHP in good faith and without malice in response to such inquiries. _________________________________ _____________ Signature Date _________________________________ Print Name Subscribed and sworn to before me this _____ day of_________________________ 20____ _____________________________ Notary Public _____________________ My Commission Expires Mail to: Office of Professional Licensure & Health Planning VI Department of Health P.O. BOX 222995 Christiansted, VI, 00822-2995 pg. 6 VIRGIN ISLANDS DEPARTMENT OF HEALTH OFFICE OF PROFESSIONAL LICENSURE & HEALTH PLANNING P.O. BOX 222995- CHRISTIANSTED, VI 00822-2995 NOTARIZED NON-ADDICTION AFFIDAVIT – ALLIED HEALTH I, __________________________________________ am not addicted to the intemperate use of illicit first, middle, last, suffix) alcohol, drugs, any prescription medications including controlled substances or any mind-altering substances that may alter or impair my judgment and ability to carry out the duties of the profession. Affidavit - NOTE: Any false or misleading information in or in connection with any application may be cause for debarment on the ground of lack of good moral character. _________________________________ _____________ Signature Date _________________________________ Print Name Subscribed and sworn to before me this ____ day of_________________ 20____ _____________________________ Notary Public _____________________ My Commission Expires pg. 7 OFFICE OF PROFESSIONAL LICENSURE & HEALTH PLANNING P.O. Box 222995, Christiansted, VI 00822-2995 Tel: 340-773-1561 PROFESSIONAL RECOMMENDATION This form must be completed and mailed DIRECTLY to the Office of Professional Licensure & Health Planning (PLHP) at P.O. Box 222995, Christiansted, VI 00822-2995. PLHP requires the completion of two (2) Professional Recommendation forms from Colleagues or Licensed Professionals who are familiar with your clinical skills and have personal knowledge of your character, personal reputation, background and professional ability. This form is confidential and required as part of the application for licensure or Allied Health clearance. All elements in the section below must be completed. The lower half of the form may be used for narrative comment. This is my authorization to send this completed form and release all information in your files, favorable or otherwise directly to the Office of Professional Licensure & Health Planning. Applicant's Name: ______________________________________________ Profession __________________________ Applicant's Signature: ______________________________________ Date: ________________ Address:_________________________________City:______________________ State:______Zip Code: ___________ ALL ELEMENTS IN THIS SECTION MUST BE COMPLETED BY THE RECOMMENDING PROFESSIONAL The information on this form is confidential, this is NOT a public document. 1. Date and type of service: ______________________________ This individual served with me as _____________________ From____________ to __________ at______________________________________________________________________ Month/Year Month/Year Location 2. Please indicate with check mark: Poor Fair Good Superior N/A Professional knowledge ❑ ❑ ❑ ❑ ❑ Clinical judgement ❑ ❑ ❑ ❑ ❑ Relationships with patients or clients ❑ ❑ ❑ ❑ ❑ Ethical/Professional conduct ❑ ❑ ❑ ❑ ❑ Ability to communicate ❑ ❑ ❑ ❑ ❑ Clinical skills ❑ ❑ ❑ ❑ ❑ 3. Recommendation (please indicate with a check mark): ❑ Recommend highly without reservation ❑ Recommend as qualified and competent ❑ Recommend with some reservation (explain) ❑ Concerns (explain) 4. Of particular value in evaluating the candidate is information regarding any notable strengths and weaknesses (including personal demeanor). We would appreciate your comments. If more space is needed please attach. 5. The above report is based on: (please indicate with a check mark) ❑ Close personal observation ❑ General impression ❑ A composite of evaluations ❑ Other Signature: ____________________________________________ Date: _____________________ Print Name: _______________________________________