Form DBPR VM13 "Change of Responsible Veterinarian" - Florida

What Is Form DBPR VM13?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR VM13 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR VM13 "Change of Responsible Veterinarian" - Florida

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State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Change of Responsible Veterinarian
Form # DBPR VM 13
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
TRANSACTION REQUIREMENTS
Change Responsible
Complete this entire application.
Veterinarian
No fee required [2602/9007]
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Information: Select this transaction if you need to update the responsible veterinarian for your
veterinary premise/clinic. The responsible veterinarian will provide professional supervision of the
veterinary medical practice and ensure the minimum standards set by the Veterinary Board are
followed.
2. Application Instructions by section
a. Section I – Clinic Information
i.
Fill out each section completely.
ii.
Provide the clinic license number.
iii.
Provide the current name of the clinic, hospital, or mobile unit.
iv.
Provide the clinic, hospital, or mobile unit mailing address. This will be used for sending
correspondence regarding your application and license.
v.
Provide the physical address of where the clinic, hospital, or mobile unit is located.
vi.
Provide a valid phone number, fax number and email address. Contact information is often
used to quickly resolve questions with applications by telephone call or email. If contact
information is not provided, questions regarding applications will be mailed to the applicant’s
mailing address and may take longer to resolve.
b. Section II – Responsible Veterinarian Information
i.
Provide the name, license number, Social Security number, address and signature of the
licensed veterinarian who is designated as the responsible veterinarian. The responsible
veterinarian will provide professional supervision of the veterinary medical practice and
ensure the minimum standards set by the Veterinary Board are followed.
c. Section III – Affirmation by Written Declaration
ii.
The applicant must sign the affirmation by written declaration.
DBPR VM 13 Change Responsible Vet
Eff. Date June 2017
Incorporated by Rule: 61-35.025
1 of 2
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Change of Responsible Veterinarian
Form # DBPR VM 13
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
TRANSACTION REQUIREMENTS
Change Responsible
Complete this entire application.
Veterinarian
No fee required [2602/9007]
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Information: Select this transaction if you need to update the responsible veterinarian for your
veterinary premise/clinic. The responsible veterinarian will provide professional supervision of the
veterinary medical practice and ensure the minimum standards set by the Veterinary Board are
followed.
2. Application Instructions by section
a. Section I – Clinic Information
i.
Fill out each section completely.
ii.
Provide the clinic license number.
iii.
Provide the current name of the clinic, hospital, or mobile unit.
iv.
Provide the clinic, hospital, or mobile unit mailing address. This will be used for sending
correspondence regarding your application and license.
v.
Provide the physical address of where the clinic, hospital, or mobile unit is located.
vi.
Provide a valid phone number, fax number and email address. Contact information is often
used to quickly resolve questions with applications by telephone call or email. If contact
information is not provided, questions regarding applications will be mailed to the applicant’s
mailing address and may take longer to resolve.
b. Section II – Responsible Veterinarian Information
i.
Provide the name, license number, Social Security number, address and signature of the
licensed veterinarian who is designated as the responsible veterinarian. The responsible
veterinarian will provide professional supervision of the veterinary medical practice and
ensure the minimum standards set by the Veterinary Board are followed.
c. Section III – Affirmation by Written Declaration
ii.
The applicant must sign the affirmation by written declaration.
DBPR VM 13 Change Responsible Vet
Eff. Date June 2017
Incorporated by Rule: 61-35.025
2 of 2
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Change of Responsible Veterinarian
Form # DBPR VM 13
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Premise/Clinic Information
CLINIC INFORMATION
Clinic License Number
Clinic Name
CLINIC MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
CLINIC LOCATION ADDRESS
Street Address
City
State
Zip Code (+4 optional)
CONTACT INFORMATION
Telephone Number
Email Address
Section II – Responsible Veterinarian Information
RESPONSIBLE VETERINARIAN INFORMATION
Name
License Number
Social Security Number*
Street Address
City
State
Zip Code (+4 optional)
Signature of Responsible Veterinarian:
Date:
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited
by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation
pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1),
Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be
used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
Section III– Affirmation by Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR VM 13 Change Responsible Vet
Eff. Date June 2017
Incorporated by Rule: 61-35.025
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