SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certification Form

Nam~e~: _ '-'-'-'le~tt'---- Social Security Number: _S __ _

Campus/Division/Program: __ W::..:...t.Y..::;O:..:.m:..:.in:..:.g/Mc,:_:,;c:;a::.:t::.:h/:..:.A~n~a:::to:::,mc.:..:.Ly.:..:/S~A..:;S::::.... ____ _ To be completed by Division Head

Degrees Held (Press "tab" in last cell to add additional row in table):

Degree Level

Bachelor of Science

Master of Science

Dr. of Philosophy

Date Official Transcript Received

06/13/1997

03/23/2004

12/21/ 2013

Granting Institution

University of California, Los Angeles

Air Force Institute of Technology

University of Albany, NY

Major Minor

Atmospheric Sciences

Meterology

Department of Earth & Atmospheric Sciences

Courses for which this faculty member meets minimum reauirements per SCP-2171: Course Courses [}ualifications/Justification

!Dept/No Title i.e. Degree level and major; graduate hours; license; certification; experiences*, etc. Provide ,necific exnlanation. Press "tab" in last cell to add additional row to table. l

MT Math A 11 courses b) degree

SC Physical Science A II Courses by degn:e

BS Biology BS 124 & 125 only by tested experience

PH Physics All Courses by degree

OR Orientation 110

Professional Develooment:

Required

__ Required

Required

r have verified the above information to the best of my ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

SIGNATURES:

Date

Vice President for Academic Affairs

•J-:..vwriences "liould meeJ 1~.'.11.!tl ,!,perr1.~n,e reqmn'IIU!tJtsfor SJ)(!Cl}ic di.'iClfllim.~s and progrwu.•'-

•*J>leas~ add conm1111ee JtlltlUft'S o.\· 1.11111ropriate. (In tlt4! ,1 ,·em t1 co,w11111ee 1s nel!dt!d to dt!lt!nmnt! \ c1lid11y of les1ed e.,·,~r,,.:m:e used III place <>/ ulf or pw·t (!f

ear·ued cri:d1.>n11al~)

SCP-2171.A, Fawlty Credemial.,· Cer1ijirn1io11 Form (03/2016) Page I of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE

BOARD OF GOVERNORS SCP-2171.A

Faculty Credentials Certification Form

Name: Social Security Number:

Campus/Division/Program: Education/online/ SAS To be completed by D1v1s1on Head ----~----~--------------------

Degrees Held (Press "tab" in last cell to add additional row in table):

Degree Level Date Official Transcript Received

Granting Institution Major Minor

Masters of Science 12/13/2002

10/29/2013

Adult & Technical Education

Master's of Education

Marshall University

Marshall l.niversity Early Childhood

Courses for which this faculty member meets minimum requirements per SCP-2171:

tourse Courses :)ualifications/Justification ept/No

Title i.e. Degree level and major; graduate hours; license; certification; experiences*, etc.

:necific exolanation. Pren "tab" in Jut cell to add additional row to table.\

ED Education All Courses by degree

OR Orientation 110

p ti ro ess1ona ID t eve oomen:

Provide

__ Required

_ _ Required

__ Required

I have verified the above information to the best of my ability. In addition, I have explained to the employee that all official

documents must be in the Human Resources Office prior to his/her first day of employment.

SIGNATURES:

Date

• t::.,,Jt'rk11c«s .,hould meel Jestt!cl ~X/Jt'rtcllCt! r,•1111ire111e11tsfnr .rpet'ijh· di.R'JJJ/i11,•.s and pro~ram.1·.

**!'least! add wmmillee 111111u1t's a., 11p11roprior<'. (/111/re t!Wnl a ,·ommillee is llt!t!llt!d 111 dt'ta mi11<' ,·alidity of te<ted t!.\'/>t!l'le11ce ,,_,._,,1111 place of ull or part c!f

l!{ll"ltf!d ~l"f!lft'IIIJOI. )

SCP-2171 .A, I· urnlty Critclem ials < ·ertijirntion Form (03/2016) Page I of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE

BOARD OF GOVERNORS SCP-2171.A

Faculty Credentials Certification Form

Name: Social Security Number:

Campus/Division/Program: To be completed by Division Head

Logan/Biology/SAS ----------

Degrees Held {Press "tab" in last cell to add additional row in table):

Degree Level Date Official Granting Institution Major

Transcript Received

Bachelor of Science 2000 Marshall Vniversity Biology

Doctor Of Chiropratic 0!>/2412004 Palmer College of Chiropractic West/ Chiropractic

life University

Courses for which this facultv member meets minimum requirements per SCP-2171:

Course Courses Qualifications/Justification

!Dept/No Title i.e. Degree level and major; graduate: hours; license; certification; experiences*, etc.

,nc:cific c:xnlanation. Press "tab" in last cell to add additional row to table.)

BS Biology BS 115, 116. 124 & 125 Only by degree .. OR Orientation 110 \. t1>t1S

p ti ro ess1ona ID t eve oomen:

Minor

Provide:

__ Required

__ Required

Required

I have verified the above information to the best ofmy ability. In addition, I have explained to the employee that all official

documents must be in the Human Resources Office prior to his/her first day of employment.

SIGNATURES:

Date

•1-:.tper1e11ces slt(lu/cl meet /1!.Hl!d t!.tpertmcr requireme11ts for -'/JI!< ijic dtsetplmes and progrt1m.,

.. l'lea.t<! ,1</d c1m1111111,:,• tttmutl!s m ap11ropria1e (/rt tlw <!WIii a ,·0111111t11e,: u rtl!<!d.:d to J..,1,•r111i11<! rnl1di1_1 ,,f1.:<1ed e_,,,._,,.; 'ttCI! tL<1!ll m place of u /1 or purr o(

eamed credc1111a/)

SCP-2171.A, Fucul!y Crede111ia/~ Certijirntion Form (03/2016) Page I of t

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certification Form

Name: Social Security

Campus/Division/Program: -----'E=n,..g.;;..;li.;:;;sh/=-S=-A=-=S'---------------------

To be completed by D1v1s1on Head

Bachelor of Fine Arts 8/ 16/ I 3

Master of Fine Arts 5/13/2017

West Virginia University

California College of Arts

Major

Writing

Writing

Courses for which this facultv member meets minimum reouirements oer SCP-2171: Course Courses ~ualititations/Justification

Minor

Photography

English

Dept/No Title i.e. Degree level and major; graduate hours; license; certification; experiences*, etc. Provide :necific exnlanation. Press "tab" in last cell to add additional row to table.\

EN English All Courses by degree

OR Orientation 110

P ti ID eve opment: ro ess1ona __ Required

__ Required

Required

1 have verified the above information to the best of my ability. ln addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

Date

•Ewene11re, slw ufd mee11e.H..-d e.,,111ri<'11<'e require11111111s f or· specific d1.1c1plin<'.< and program.<.

••Pf,:a.fe ad,f co111111111ee 111i11u1es as appmpnatlf (In tlr<' ,:1·11m a rnm11111/,:,: 1.< needrd rn det,•1·1111111: rnluliry oftesii:d e.vp,:,-ience 11.,e,I i11 pluce vfa/1 or ptirl of

ttorned cn!(flt,rttal.)

SCP-2171.A, hKufty Credemiaf.~ ( ·errijicurion I-"orm (03/2016) Page I of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certification Form

Name: Social Security Number: _ ------

Campus/Division/Program: ___ O"-n""l""in;.;..;e"'"/"-Ps;;;.y""'c;.:.;h;.;:.o.:..;lo""g,.,_y-'-'/S::..:A~S

To be completed by D1v1s1on Head

D.ee:rees Held (Press "tab" Jn lastt!dl to add additional row jn tablP)~. D'i!gree C:iver uate Uffic1al 'G'rantmg Thsfil6,mo

Bachelor in Psychology

Master in Psychology

Doctor of Philosophy

Transcript Received

05/27/1979

05/09/1981

5/11/2005

Berea College

Eastern Kentucky University

Trinity Theological Seminary and Trinity College of the Bible

Major Minor

Psychology/ Child Devlopment

Clinical Psychology

Philosophy in Biblical Counseling

Courses for which this facultv member meets minimum reauirements oer SCP-2171: Course Courses ~ualifications/Justification

Dept/No Title i.e. Degree level and major; graduale hours; license; certificalion; experiences*, etc. Provide ,necific cxnlanation. Press "tab" in last cell to add additional row to table.\

PY Psychology All Courses by degree

OR Orientation 110

P fi l D ro ess1ona eve ooment:

__ Required

_ _ Required

Required

I have verified the above information to the best ofmy ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

Date

•£.rJNriences .~houlcl meet ft!.,., .... d tt ,·,,er,1,.•nce reqmreme,us j or .\peqJic dtsc:,plm<s und pro~i:rm11s

-*l'lo!ase add co111111111,•e 11m1u1o!s <1.< ll/Jpropriate. (ill rh~ ,·,·enl <1 conr111111ee 1s needed,., d~1er111111e rnlulir.1 oftes1ed e.,pe,·1e11ce used III place of all or p,11·1 of

e,mr~ I c1'1!</,•1111al.J

SCP-2 171.A, Faculty Credentials Certijicalion Form (03/2016) Page I of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certification Form

Name: Social Security

Campus/Division/Program: ----=E::.:n:,I;.g:i.:.l.:.::is~h::../.:a:S.:..A:.:S~------------------

To be completed by Division Head

Bachelor of Fine Arts 2003

M &liter of Fine Arts 2007

Morehead state University

Morehead State University

Major

English

English

Courses for which this facultv member meets minimum reQuirements ner SCP-2171: Course Courses :)ualitications/Justification Dept/No Title i.e. Degree level and major; graduate hours; license; certification; experiences*, etc.

,necifk exnlanation. Press .. tab" in last cell to add additional row to table.\

EN English All Courses by degree

OR Orientation I IO

p fi ro ess1onal Deve opment:

Minor

Provide

Required

_ _ Required

Required

I have verified the above infonnation to the best of my ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

Date ,r:,(t1 Date

•h-.tperif!m:es :;/wuld mc!et restt:d ~.rpl!ric.~ncl! r.:quirementsfor specific di.fCtplin,1.'i w-ul progrt.m1s.

**1'11!<1.<I! odd commillel! mi11utl!s m- appro/JIWte (Ill the l!l"1!'11 a wn1111111ee is needed w d.-t,'Tlllllt<' l'(I/idm ,,ftested l!.tper1e11<·e 11ud in pt.ice of all or pan of

l!arm:d c:r1td,:1uwl,)

SCP-2171.A, Farnlfy Credemials Certijkation 1-"orm (03/2016) Page 1 of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certification Form

Name: Social Security Number: - ___ _

Campus/Division/Program: ---'O""n""l""in"'e:::../=:.So""c::.:i.::.al:..;S:;:.;c::.:i.::.en:.:;c::.:e:.::s!:.:S~A.!:S~--­To be completed by D1v1s10n Head

Degrees Held (Press "tab" in last cell to add additional row in table):

Degree Le,·el

Bachelor of Arts

Master of Arts

Date Official Transcript Received

5/01/2001

2003

Granting Institution

Wesl Virginia State University

Marshall l 1niversity

Major

History

Communications/

Social Sciences

Courses for which this facultv member meets minimum requirements oer SCP-2171: Course Courses Qualifications/Justification

!Dept/No Title i.e. Degree level and major; graduate hours; license; certification; experiences*, etc. •necific e11nlanalion. Press .. tab., in last cell to add additional row to table.\

HS History All Courses by degree

SP Speech All Courses by degree

so Sociology All Courses by degree

PS Political Science All courses by degree

OR Orientation 110

p fi ro ess1ona eve oomen: ID t

Minor

Provide

__ Required

__ Required

Required

1 have verified the above information to the best of my ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

SIGNATURES:

Date

• f;_rpe, rt'nces .should met.I Jeslr'd t!''Jh!rlc!m.'e rt!qttirem~ms for \pe,Jjic ,flsetpfm.,•s and pro~r,1111.t

** /'lease .-,def coim11111e,: 111111utes m appropnal,:. (/111/w ere11I a con1111111~e ts 11e,~h·d w ,le1er111me ,·i,lldilJ, ,,; l,:s1ed expenence used III pface of all or pan of

earued c,-c!dt.>n/ial.)

SCP-2171 .A, Furn/(y Credemia!I Cer1ijk(J{io11 Form (03/2016) Page I of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certmcation Form

Name: Social Security Number:

Campus/Division/Program: Williamson Campus/School of Allied Health and Nursing/Medical Assisting To be comple(Cd by Di'vision Head

Degrees Held (Press "tab" in last cell to add additional row in table):

DqreeLevel

AAS

Date Official TnJUtript Received

Granting Institution

SWVCTC

Counes for which this faculty member meets minimum requirements per SCP-2171: Coone Courses IQuaJlflcatiou/Justificatioa

Major Minor

MA

Dept./Nc Title i.e. Detrte level and major; araduate hours; license; certification; experiences•, etc. Provide !Specific explanation. Press "tab" in last cell to add additional row to table.)

lnlrocu:lian IO~ MA 100 Assisting AAS. Medical As1111ing; Cfinieal E,cperiance; CCMA, NRCPT, NRCCS, NRCPhT, NRCMA. NRCEKG

MA 105 Medi;.al Olf109 Billing & mdi"I I M!L Med..,,,......._,. CCWl;NRCCI

MA101 Mtd'ocalAuilltlngl NS. Madeal ANiSling: Clinic:al ~ : COM. NACPT, NRCCS, NRCPhT. NRCMA. NREKG

MA106 -10ffc.lM .. & ...... . · MS.-M>l!lioa· OCMA:NRCCI

MA201 Medici! Anlllting N MS, Medical Asli$1ing: CCMA, Clinical Experience; NRCPT, NRCCS, NRCPhT, NRCMA. NREKG

Mll.210 M9Clicel Assisting It MS, Medical Altitting; CCMA. Clt!'•gl Expwiencie; NRCPT. NRCCS, NRCPhT. NRCMA, NREKG

MA225 Mad cal AH atina Caplb'le MS, Medica Anlteing, CCtM: C inical !xperience: NRCPT NRCCS NRCPhT. NRCMA, NREKG Professional Development: A,M_ - r:\-L l r.J', •. -~ /r}f1- Att (I hUJ2$&S

__ Required Cllapman,rile Middle Sc:hool: 81h Gn.de Cl!INr Day Novtmb" 2. 2017 8:30·11.30

__ Required Open Hous.Wlilmson C8mpus Oclaber2~. 2017 ~7PM

NaloonalAQOQa!ion for Heafth PIDleMion81t. NRCCS NRCEKG, NRCMA, NACPhT. NRCPT 5115/2017•5115/2018

__ Required EnrolmMI Manag.,.,.nt Commit\"; C\lrriGUlwm •"'1 ln1tM.1ion CommiUff; Gcm1m1S101 Day ~ •ngi

llladcboetd Tlllining e,1M7 Required

Allied tte.ith Paihway WoNhop 519/2017 Required

Basic Lift Support ~17-612019; Firsl Aid/CPR/AED 6130117-6/2019 Required

Patienl Simulalor EINfllielsC-JSTAN Tiw.ng No.ember9.2016 Required

Open HouH No .. mber 15,2016•W,hamson C1mp,11 Required

American Heal Aslac:i8tion·~ PfOwider 61l6/15-612812017 Required

Nalionll Aalocialion for Heatth Professionals. NRCCS. NRCEKG. NRCMA, NRCPhT. NRCPT 511Sl2015-511S/2016 Required

Poekfll nu11e-Eduealcr Luncheon May 19,2016· Mamotl Chatteston Wt/ __ Required

Conlilvno Educalicn Craclils for N-.e1 Assoel8bon lor He.alll ProfelllDnllb-year 20166 cndits __ Required

Flu Shol-Vrtel Cheel< wilh Rite Aid-Wyoming Campus Monday, Oclobet 3,2016 __ Required

Facully Prof••~ Devetosw,,enl Al-meo1 Wlllkshop: Dr. AnderlOrl. Odobtr 211, 2016 Logan Cempus 9-1:00 . Required

Conin.,g Education c:nidils fat NllliDnaJ Almeaa!icn lor HHltn Ptofestionela yew 2015-6 credils Required I have verified the above infonnation to the best of my ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

SIG NA ~ES: .r. f: ff _ _

l~~~ ~ /2,CJ? £ CZ2IJi?'iZ /k> /4w DivD· · Head J7

_·ti/imCuvt.D Date

Vice President for Academic Affairs l3o·~

Date

• Ex~rie,rces .should meet tested eJqRrlettce nqu1remen1s for specific disciplines and programs. • •Please odd committee minutes tu appropriate. (J,r the evtml a committr, rs netded 10 determme validity of tested experienct used In place of all or par, of earned crede,rtial.)

SCP-2171.A, F acult)' Credentials Certification Form (0312016) Pagel of I

(

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certltlcatloa Form

Name: Social Security Number:

Campus/Division/Program: _ __________ _ _________________ _

To be completed by Division Head

telrees Held (Press "tab" la last cell to add additional row in table):

Dep-eel.evtl Date Oflldal GnntiD1 lutitutlon Major Minor Tnucript Reeeived

B.S. August 1974 West Virginia Institute ofTechnology ~eelrical-+ >--- -•- . .

- ·-- -.! _ Engineering

I - I ! 1

Coarse, for wblch tbil facu Jastif'acaCion Co■ne

pt/N Coanes

TIiie el and major; aradaace houn; lleeme; certification; esperle■ces"', etc. Provide

Registered Professional Engineer (PE) via the West Virginia 8o8fd of Registration of

Professional Engineers since 1982. Resjsttation No. 8573.

P ti • IDe I ro essJODI ve ODment:

30 hours of professional development required for bi-annual renewal of my PE license. __ Required

__ Required

__ Required

_,

I have verified the above infonnation to the best of my ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

Date

~ "S' .. I Date

•Exp,rltncu should IMtt ttlltd ap,rl,"" requlrffllffllS/or sp,cijlc discipliMs and prograwu. ••Pltau add commlnu mJ11111ts as appn,prlot,. (In 1M n,nt a committff is Mtded to d11,rmlne validity of ttslld up,rltnc, ""'1 ,n p/4ct of all or port of

ff1111#d cndtntlal.)

SCP-2171.A, Faculty Credentials Certification Form (03/2016) Page 1 of I

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Cerdflcation Form

( - Name: Social Security Number:

(

Campus/Division/Program: Lopp caumus/Engioeering/lnformation Technology To be completed by Division Head

Held (Press "tab" ID last cell to add additional row ID table): -

DeareeLevel Date Official Graat101 lutitudon Transcript Reeeivecl

Bachelor Aug 2002 tMarshall Univcristy

- ---·-- ~ - --- -

-

Courses s/Juttflcation

Major Mia or

·Management ilnfonnation Systc_~s_

--' I I - -

Title evel and major; graduate boun: lieeme; certiRcatlon; e:s.periences*, etc. Provide _ptJon. Press to add additlona

Profi l I Dev I t ess ona e opmen: __ Required

_Required

_ Required

I have verified the above infonnation to the best of my ability. In addition, I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment

Date

•&p.riellDls sho11ld mut tllttd ,~riencf r,quln-nujor 6/MCf/lc dutlpllnes and prog,runs.

.. Plua add comm/tiff mlnulls 08 approprlatl. (In tit, ,wnt a comm/II# u nnet.d ID tkllrmtM 'IIOl1dity ojtlmd uperlena tutd In place of all or par/ of

earMd cred,ntlaL)

SCP-2171.A. Facultv Credentials Certification Form (03/2016) PHC I of 1

SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

SCP-2171.A Faculty Credentials Certification Form

Name: Social Security Number:

Campus/Division/Program: School of Allied Heath & Nursin&-Lopn C8mpus/SWJical Tech To be completed by Division Head

rees Held Press "tab,. In lut cell to add additional row in table :

AAS

RBA

J>eareeLevel Date Official Tnaacript Reeelved

Grantia1 Institution

SWVCTC

Bluefield State College

Counes allflcttlons/Jusdfteatlon

Major

,Surgical j.Technolo&Y, RBA

Mlaor

Title I.e. Dearee level aad major; graduate boun; license; eertlfleation; experiences*, etc. Provide Hie ex nation. Preu ........ In lut cell to add addhloaal row to table.

ational Certified• Surgical Technologist AAS with 16 Plus years of Surgical Experience and 8 years of chin ex ience

urg. Tech Skills

rg. Tech I AAHEP Qualification for Program Director must possess an Associatc's Degree or Higher

urg Tech IJ

urgTech III

logy

kills Seminar Review

P feat IDev I ro ona e ooment: Completed RBA from Bluefield State University December 2018 _ Required Continuing Education Hours CElJ'S as required by AST for certification _Required

_ Required

I have verified the above infonnation to the best of my ability. In addition. I have explained to the employee that all official documents must be in the Human Resources Office prior to his/her first day of employment.

Division 1/ ~ .... ~ .... ~-"""""'-­Vice~- for Academic Aftairs

•Exp.,11nca 1ho11fd •it lltllld exp,ri1n« ~i"1ll'lllntsfor 8JJ«ific disc,pfinu and p,ogranu .

Date

I · _az, , t't Date

.. PIIO# add conuniti., mmutu a, approp,late. (In IM flW!nt a commlttet IJ Med«/ lf)(llllrm/M valldltyof t1Jt1d1:,q,,rt11" 1111td In ploce of all or pa,1 of

tamed cndential.)

)

SOUTHERN WEST VIRGINIA COMMUNITY ANDTECHNICA.l.COLLECI BOARD or GOVERNORS

SCNl71.A lfaadty CndlD1illa ClfClftalda ,_

Campull>lvl.....,.._: 14111D "'1lpegl$slMpg e(Cfwr ID4 Isbobal baUwttfealos To lie complclld bJ DMtlon Had

MSN

ISN

AON

Dalt Offlelal GnDllq llldbtloo Tnmcripllttcelvd

AulVst. 2001 Mlnhlll Unlwarllly

MIY,lllt swvcrc

Sprlfll Columbus StN Cmnmunlly Collep

t.lllltltlcatlln

Nunlnl Mmln,

Nul'llnl

Mlaor

llftl ud _.,, paduatelnl'll llcewl ardffatlaaa apwl•w", etc. Pnwkll llatloD. ,,_ ...... la lalt .U ID lllld lddfllanal rt/Ill to table.

• CUrrent WV NUl'IIIW LICIMe

-Cunant WV Nunlftl Llc:enle

-CunentWV Nu- lbllN

CURnt WV Nut11111 License

-CurNnt WV Nurllftl Llctftle

WV80N Rtquhmlntfor llrenll,wya,ty 112 GJ1)-1utrenawal-0ct, 2017 _)CReqllrm

CNOR Ill CIiis cmr S yur plflod • llnewal MIY 5 ...,. LIit renawal 2016 _Requhal

leldtflh• Development for COOrdlnetar for Nurt1111 Polltton-Rtq. WVION _Raprfmt

I ha,ic wriffcd 1hc 1bovo l1Rlnnatloa to thc bal ofmy abllhy. In addldon. I have explained la thc cmplO)'l:lC chat Dlt offlcfll documcall

111111& bll ln lbc H11111111 Raoun:a omce pdor to hlslller nna day of employmlftL

(

( )

SICNATURIS:

DlvlllaD .....

DIie

•EJtp,,tu,t:a .dttaltl _,,.,. .,,,.,.,_ ,.,,,,.,,,..,,,,. l/lfff/k dbdpH,,n ""',,,._,,

••Plws altl wlltn •lnlda t11a,p.,.,_. (111 lhl MllloCO#lalltH It wdtdto..,,,_ WJlldlt,o/lfllMll,.,,,,,_ ualllf

pion" oil,,,.,.., of ffJIWtl t:ntlutlloL)

SC:,..2171.A, F«lllly Owlnllall~lo,, For. (OJIZOl6) ..... .,,