Form DBPR VM10 "Authorization for Interstate Exchange of Examination and Licensure Information" - Florida

What Is Form DBPR VM10?

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 April 1, 2013;
  • 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 VM10 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DBPR VM10 "Authorization for Interstate Exchange of Examination and Licensure Information" - Florida

1368 times
Rate (4.5 / 5) 68 votes
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Authorization for Interstate Exchange of Examination and Licensure Information
Form # DBPR VM 10
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.
PART A- Applicant Information: The applicant is to complete Part A only and forward the entire form to
the appropriate state to complete Part B.
APPLICANT INFORMATION
This form is essential to the application you are filing with this Board. Before approval of your application,
the Board of Veterinary Medicine must verify your examination history and/or licensure status. Please
complete the initial portion of this form and then forward it to the state in which you are licensed or
have previously been licensed. That Board, in turn, will complete the remainder of this form (Part B)
and return it to this agency. (You are advised to check with the Board before forwarding this form to
determine if there are additional requirements and/or fees charged before such information will be
released.) This form must be filled out by all states in which you previously have taken an examination or
become licensed.
TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):
Last Name
First
Middle
Title
Suffix
Address
License Number (if applicable)
City
State
Zip Code
Phone
Date of Birth
Social Security Number*
*Under the Federal Privacy Act, disclosure of Social Security Numbers is voluntary unless specifically required by
Federal status. In this instance, social security numbers are mandatory pursuant to Title 42 United States Code,
Section 653 & 654; and sections 445.203(9), 409.2577, & 409.2598, Florida Statutes. Social Security numbers are
used to allow efficient screening of applicants & licensees by a Title IV-D child support agency to assure compliance
with child support obligations. Social Security numbers must also be recorded on all professional & occupational
license applications & will be used for licensee identification pursuant to the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193,Sec. 317.
I hereby request and authorize any institution with whom I have been associated to provide any and all
pertinent information requested in this form concerning my qualifications for professional licensure to the
Florida Department of Business and Professional Regulation Board of Veterinary Medicine to complete
an application filed with that agency. I hereby release the institution and all individuals connected
therewith from all liability for any damage whatsoever incurred by me as a result of their furnishing such
information.
____________________________________________________________________
_____________/_________________/______________
Applicant Signature
Date Signed
DBPR VM 10
Effective April 2013
Incorporated by Rule: 61-35.025
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Authorization for Interstate Exchange of Examination and Licensure Information
Form # DBPR VM 10
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.
PART A- Applicant Information: The applicant is to complete Part A only and forward the entire form to
the appropriate state to complete Part B.
APPLICANT INFORMATION
This form is essential to the application you are filing with this Board. Before approval of your application,
the Board of Veterinary Medicine must verify your examination history and/or licensure status. Please
complete the initial portion of this form and then forward it to the state in which you are licensed or
have previously been licensed. That Board, in turn, will complete the remainder of this form (Part B)
and return it to this agency. (You are advised to check with the Board before forwarding this form to
determine if there are additional requirements and/or fees charged before such information will be
released.) This form must be filled out by all states in which you previously have taken an examination or
become licensed.
TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):
Last Name
First
Middle
Title
Suffix
Address
License Number (if applicable)
City
State
Zip Code
Phone
Date of Birth
Social Security Number*
*Under the Federal Privacy Act, disclosure of Social Security Numbers is voluntary unless specifically required by
Federal status. In this instance, social security numbers are mandatory pursuant to Title 42 United States Code,
Section 653 & 654; and sections 445.203(9), 409.2577, & 409.2598, Florida Statutes. Social Security numbers are
used to allow efficient screening of applicants & licensees by a Title IV-D child support agency to assure compliance
with child support obligations. Social Security numbers must also be recorded on all professional & occupational
license applications & will be used for licensee identification pursuant to the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193,Sec. 317.
I hereby request and authorize any institution with whom I have been associated to provide any and all
pertinent information requested in this form concerning my qualifications for professional licensure to the
Florida Department of Business and Professional Regulation Board of Veterinary Medicine to complete
an application filed with that agency. I hereby release the institution and all individuals connected
therewith from all liability for any damage whatsoever incurred by me as a result of their furnishing such
information.
____________________________________________________________________
_____________/_________________/______________
Applicant Signature
Date Signed
DBPR VM 10
Effective April 2013
Incorporated by Rule: 61-35.025
PART B- Licensure Verification
LICENSURE VERIFICATION
State verification information to be completed by the state board.
Applicant Name
License Number
Title of License
Date of Original Issue:
/
/
LICENSE TYPE
 Permanent
 Temporary
 Other (explain):
LICENSE STATUS
 Active/Current
 Inactive
 Void
 Other:
METHOD OF LICENSURE
 Examination
 Without Examination
 Grandfathering
 Reciprocity
 Endorsement
If Endorsement, explain qualifications for endorsement:
LICENSE DISCIPLINE
Provide explanation if any type of disciplinary action has been taken against the license.
 No Disciplinary Action
 Suspended
 Revoked
 Invalid
 Other Discipline
Explanation:
AFFIRMATION STATEMENT
I affirm that I have provided the above information completely and truthfully to the best of my knowledge.
State Board of: _______________________________
Phone Number: ____ . ____ . _____
Official’s Signature:
Date: ____/____/_____
Print Name:_____________________________________________________
Title:___________________________________________________________
Please mail the completed form to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
DBPR VM 10
Effective April 2013
Incorporated by Rule: 61-35.025
Page of 2