Texas Standardized Credentialing Application	           Attachment C – Other Work History 

PREVIOUS PRACTICE/EMPLOYER NAME
     

	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE
     	
PREVIOUS PRACTICE/EMPLOYER NAME
     	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE
     	
PREVIOUS PRACTICE/EMPLOYER NAME
     	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE
     	
PREVIOUS PRACTICE/EMPLOYER NAME
     

	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE
     	
PREVIOUS PRACTICE/EMPLOYER NAME
     	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE
     	
PREVIOUS PRACTICE/EMPLOYER NAME
     	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE
     	
PREVIOUS PRACTICE/EMPLOYER NAME
     	START DATE/END DATE (MM/YYYY TO MM/YYYY) 
              	
ADDRESS
     	
CITY	STATE/COUNTRY	POSTAL CODE
     	     	     	
REASON FOR DISCONTINUANCE