MILITARY SPOUSE/AFC CANDIDATE PROGRAM APPLICATION
Prior to completing this application, please read and observe the following:
IV. APPLICATION
IDENTIFYING INFORMATION
Last Name: / First Name: / Middle Initial:Date of Birth: / SSN: / Tax ID Number: / Drivers License # and State:
Street Address: / City: / State: / ZIP Code:
Email address: / Phone Number:
EDUCATION
Please provide the appropriate information for the school that issued your highest degree completed.Degree Awarded / Institution/School Issuing Degree / Campus Location / Date Graduated
If your degree was awarded under a name different from your present name, include the name you were using:
TRAINING
Institution Name / Specialty / Date Completed
PROFESSIONAL CERTIFICATIONS
Certificate / Date Received / Date Expires
WORK HISTORY
Please include a chronology of relevant work history for the past five years. Please explain any gaps in work history that are greater than six months. Attach additional sheet if necessary.
Employer Name / Start Date (MM/YY): / End Date (MM/YY):
Address / City/State/ZIP
Employer Name / Start Date (MM/YY): / End Date (MM/YY):
Address / City/State/ZIP
Employer Name / Start Date (MM/YY): / End Date (MM/YY):
Address / City/State/ZIP
Employer Name / Start Date (MM/YY): / End Date (MM/YY):
Address / City/State/ZIP
Employer Name / Start Date (MM/YY): / End Date (MM/YY):
Address / City/State/ZIP
GAPS IN WORK HISTORY
Include an explanation of any gap (s) six (6) months or greater.
Explanation / Start Date (MM/YY): / End Date (MM/YY):
Explanation / Start Date (MM/YY): / End Date (MM/YY):
STATEMENT OF UNDERSTANDING AND RELEASE
I hereby certify that the information provided in this application is true and accurate and reflects my current level of training, experience, and demonstrated competence to practice with the privileges I have requested. I understand that I have the burden and legal responsibility of providing true and adequate information to demonstrate my professional competence, character, moral ethics, and other qualifications. I further understand that any significant misstatement or omission on this application may constitute cause for denial of participation or dismissal from MHNGS or be subject to applicable state or federal penalties for perjury.
I further authorize the copy of my signature on this document, as part of the application, to be as binding as the original. I agree that MHNGS, its representatives and individuals or entities providing information to MHNGS in good faith shall not be liable for any act or occasion related to the evaluation or verification contained in this document, which is part of the application. I further agree to notify MHNGS in a timely manner of any change to the information requested in this application. Information requested in this application that is not publicly available will be treated as confidential by MHNGS.
I declare under penalty of perjury that my academic relationship with the AFCPE is in good standing. I agree to notify MHNGS within ten (10) days of any change to the status of my standing with AFCPE, and I agree to forward documentation verifying all AFCPE exam scores.
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Applicant SignatureDate
Fax the completed form to 571-227-6720 (Attn: Roy Werthmuller)