Form 220

the inclusive dates you so practiced, and each location where you so practiced in the past ten years, or provide your curriculum vitae including such information. (7) If you have held any teaching positions, for each institution, state: (a) The name and address of the institution; (b) The inclusive dates of your association; and (c) The title held in each position. (8) State the name and location of any hospital or medical facility at which you have or have had appointments and/or clinical privileges in the past ten years, and the dates you had such appointments or privileges. (9) Identify each medical book, paper, article, or other document that you have published, written, or contributed, and for each, state the title, whether you were an author, co-author, or contributor. (10) State the name of every jurisdiction in which you are or have been licensed as a health care provider. (11) State whether you are, or have ever been, a member of any medical or other health care provider association, society or organization, and if so, as to each such membership, state: (a) The name and address of the medical or other health care provider association, society, or organi- zation; (b) The inclusive dates of your membership; and (c) Whether you have ever held any office and, if so, the title of the office and the dates you held such office. (12) With respect to any medical specialty board or other specialty board, for each board state, whether you were refused or granted certification, the reasons therefor, and, if granted certification, your title or rank (e.g., diplomate, fellow, member), and whether you still hold such certification, title, or rank. (13) During the past ten years have you ever had your privileges or application for privileges denied, revoked, restricted, suspended, or limited in any way at any hospital or medical facility? (14) Unless agency or another vicarious liability relationship is admitted to such codefendant, state whether at the time of the negligence alleged in the Complaint to the present you were an officer, shareholder, employee, member, partner, or otherwise affiliated with any entity or person involved in the care and treatment of the Plaintiff. If the answer is yes, describe the nature and time period of the affiliation. (15) During the ten years prior to the negligence alleged in the Complaint, have you ever had your application for a license denied, revoked, restricted, suspended, or limited in any way in any jurisdiction? (16) State the time period(s) of the physician-patient relationship, if any, you had with the Plaintiff. (17) With respect to the negligence alleged in the Complaint, did you ever consult with any physician or other health care provider regarding your diagnosis, care, or treatment of the Plaintiff that is not