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- [divbox=white][hr][/hr][center][img]https://i.imgur.com/YNwKrcn.png?1[/img]
- STATE OF SAN ANDREAS
- LICENSE TO PRACTICE MEDICINE APPLICATION FORM[/center]
- [hr][/hr]
- [list=none][b][center]SECTION ONE - PERSONAL INFORMATION[/center][/b][/list][hr][/hr]
- [list=none]
- [b]1. TITLE:[/b] MS
- [b]2. FULL NAME:[/b] Charlotte Watson
- [b]3. DATE OF BIRTH:[/B] 5/15/1981
- [b]4. PLACE OF BIRTH:[/b] Santa Flora, San Fierro.
- [b]5. AGE AT TIME OF APPLICATION:[/b] 37
- [b]6. PHONE NUMBER:[/b] 555-1589
- [b]7. E-MAIL ADDRESS:[/b] CharlotteWatson81@lsmail.com
- [b]8. DOMESTIC ADDRESS:[/b] 1178 Mildred Avenue, Marina, Los Santos, 313 San Andreas
- [/list]
- [hr][/hr]
- [list=none][b][center]SECTION TWO - PERSONAL HISTORY[/center][/b][/list][hr][/hr]
- [list=none]
- [b]9. HAVE YOU EVER GONE BY ANOTHER NAME? IF YES, LIST ALL THAT ARE APPLICABLE BELOW:[/b]
- [list=1][*] N/A[/list]
- [b]10. HAVE YOU EVER BEEN CONVICTED OF BREACHING ANY OF THE SAN ANDREAS LAW OR THAT OF ANOTHER COUNTRY?: IF YES, EXPLAIN IN THOROUGH DETAIL:[/b]
- [list=1][*] N/A[/list]
- [b]11. LIST ALL AND ANY EDUCATION THAT YOU HAVE ENROLLED IN. ADD MORE FIELDS IF NEEDED:[/b]
- [list=none][b]NAME OF HIGH SCHOOL:[/b] Hashbury High School
- [b]YEAR GRADUATED:[/b] 1999
- [b]DEGREE(S) EARNED:[/b] High School Diploma
- [b]NAME OF COLLEGE:[/b] San Fierro Medical Center
- [b]YEAR GRADUATED[/b]: 2002
- [b]DEGREE(S) EARNED: Bachelors Degree[/b]
- [b]TYPE OF MEDICAL DOCTOR: M.D Medical Doctor
- [b]MCAT SCORE (COMPLEX-USA SCORE IF D.O):508[/b]
- [b]RESIDENCY LOCATION: San Fierro Medical Center[/b]
- [b]SPECIALIZATION:Family Medicine[/b]
- [b]AFFILIATIONS AND OR BOARD CERTIFICATIONS:American Board Of Family medicine[/b]
- [b]NAME OF UNIVERSITY:[/b] Los Santos University
- [b]YEAR GRADUATED:[/b] 2012
- [b]DEGREE(S) EARNED:[/b] Medical Doctorate[/list]
- [b]12. LIST ALL AND ANY PREVIOUS EMPLOYMENT. ADD MORE FIELDS IF NEEDED:[/b]
- [list=none][b]NAME OF EMPLOYER:[/b] Burgershot
- [b]PLACE OF EMPLOYMENT:[/b] Burgershot
- [b]OFFICIAL COMPANY TITLE:[/b] Burgershot
- [b]JOB DESCRIPTION:[/b] Cashier
- [b]DATE EMPLOYED:[/b] 1/12/1997
- [b]DATE DISCHARGED:[/b] 5/16/2000
- [b]REASON OF DISCHARGE:[/b] Resignation
- [/list]
- [list=none][b]NAME OF EMPLOYER:[/b] Victim Clothing
- [b]PLACE OF EMPLOYMENT:[/b] Victim Clothing
- [b]OFFICIAL COMPANY TITLE:[/b] Victim Clothing
- [b]JOB DESCRIPTION:[/b] Cashier/Store Manager
- [b]DATE EMPLOYED:[/b] 6/2/2000
- [b]DATE DISCHARGED:[/b] 4/20/2005
- [b]REASON OF DISCHARGE:[/b] Resignation
- [/list]
- [list=none][b]NAME OF EMPLOYER:[/b] Subway
- [b]PLACE OF EMPLOYMENT:[/b] Subway
- [b]OFFICIAL COMPANY TITLE:[/b] Subway
- [b]JOB DESCRIPTION:[/b] Cashier
- [b]DATE EMPLOYED:[/b]4/26/2005
- [b]DATE DISCHARGED:[/b] 12/05/2006
- [b]REASON OF DISCHARGE:[/b] Resignation
- [/list]
- [list=none][b]NAME OF EMPLOYER:[/b] San Andreas Department Of Motor Vehicles
- [b]PLACE OF EMPLOYMENT:[/b] San Andreas Department Of Motor Vehicles
- [b]OFFICIAL COMPANY TITLE:[/b] San Andreas Department Of Motor Vehicles
- [b]JOB DESCRIPTION:[/b] Road Test examiner.
- [b]DATE EMPLOYED:[/b] 1/02/2007
- [b]DATE DISCHARGED:[/b] 1/26/2013
- [b]REASON OF DISCHARGE:[/b] Resignation
- [/list]
- [list=none][b]NAME OF EMPLOYER:[/b] Fort Carson Medical Center
- [b]PLACE OF EMPLOYMENT:[/b] Fort Carson Medical Center
- [b]OFFICIAL COMPANY TITLE:[/b] Fort Carson Medical Center
- [b]JOB DESCRIPTION:[/b] Residency - Family Medicine Physician
- [b]DATE EMPLOYED:[/b] 2/15/2013
- [b]DATE DISCHARGED:[/b] 8/23/2018
- [b]REASON OF DISCHARGE:[/b] Resignation
- [hr][/hr]
- [list=none][b][center]SECTION THREE - LICENSING BASED QUESTIONS[/center][/b][/list][hr][/hr]
- [list=none]
- [b]13. WHAT SORT OF PRACTICE/PROFESSION ARE YOU AIMING TO PURSUE IF LICENSED?:[/b]
- [list=none]
- [X] NURSING
- [ ] DOCTOR[/list]
- [b]14. HAVE YOU EVER BEEN TRAINED IN BASIC LIFE SUPPORT AND/OR INTERMEDIATE LIFE SUPPORT?:[/b]
- [list=none][X] YES (WHO WAS THIS PROVIDED BY?: (San Fierro Medical Center)
- [ ] NO[/list]
- [b]15. PLEASE EXPLAIN IN FURTHER DETAIL WHY YOU WISH TO ACQUIRE A LICENSE TO PRACTICE MEDICINE:[/b]
- [list=none]Well, I've worked in this field before and I just moved back into Los Santos after a hiatus. This is my passion, I love to help people
- I don't think I would be happier doing anything else if I'm being honest. It's something I enjoy doing, I wouldn't pass it up for a million dollars
- the feeling you get when you help people is a great feeling that can't be replaced. If I recieve this, I plan on applying at the Los Santos County
- Clinic since I've heard wonderful things about it.[/list]
- [/list]
- [hr][/hr]
- [list=none][b][center]SECTION FOUR - DECLARATION[/center][/b][/list][hr][/hr]
- [list=none][quote][justify]I, Charlotte Watson, hereby declare that all of the information stated within this application is true and is as accurate to my knowledge as possible. I accept that, should I be found to have lied regarding any information, I am subject to immediate disciplinary action without question. I also affirm that I understand that, should my license be accepted, I am required to learn and follow acts up to and regarding the Hippocratic Oath. This declaration also serves as a confirmation that I have filled in all aforementioned details on my own and not by another.[/justify]
- DATE: 09/08/2018
- SIGNATURE: Charlotte Watson[/quote][/list][/divbox]
- SIGNATURE: ANSWER[/quote][/list][/divbox]
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