"Military Automatic Licensure Application" - Arkansas

Military Automatic Licensure Application is a legal document that was released by the Arkansas Veterinary Medical Examining Board - a government authority operating within Arkansas.

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Arkansas Veterinary Medical Examining Board
Military Automatic Licensure Application
In accordance with Ark. Code. Ann. § 17-1-106, the Arkansas Veterinary Medical Examining Board (Board)
will grant automatic licensure to you or your spouse if you meet the applicant criteria listed below and
submit proper documentation.
Applicant Information:
____________________________________________________________
_____ - _____ - ______
Name (First, Middle, Last)
Social Security Number
_____________________________________________________________________________________
Address (City, State, Zip)
____________________________________________________________
(____) ____ - ________
Email Address
Phone Number
____/____/____
_____________________
______________
___________________
Date of Birth
Place of Birth
Sex
Race
Applicant Criteria:
1. Type of License
Please check one of the following license types:
o
Veterinarian
o
Veterinary Technician/Technologist
2. Military Status
Please check one of the following criteria for automatic licensure:
o
I am in active military duty stationed in Arkansas.
o
I am a returning military veteran with honorable discharge within the past twelve (12)
months.
o
I am the spouse of someone in active military duty stationed in Arkansas, or the spouse
of a returning military veteran with honorable discharge within the past twelve (12)
months.
3. Proof of Military Status
Please check one of the following and submit a copy:
o
Leave Earning Statement (LES)
o
Letter from Command
o
Copy of Orders
o
DD-214 showing “honorable discharge” (veterans)
Continue to next page
Arkansas Veterinary Medical Examining Board
Military Automatic Licensure Application
In accordance with Ark. Code. Ann. § 17-1-106, the Arkansas Veterinary Medical Examining Board (Board)
will grant automatic licensure to you or your spouse if you meet the applicant criteria listed below and
submit proper documentation.
Applicant Information:
____________________________________________________________
_____ - _____ - ______
Name (First, Middle, Last)
Social Security Number
_____________________________________________________________________________________
Address (City, State, Zip)
____________________________________________________________
(____) ____ - ________
Email Address
Phone Number
____/____/____
_____________________
______________
___________________
Date of Birth
Place of Birth
Sex
Race
Applicant Criteria:
1. Type of License
Please check one of the following license types:
o
Veterinarian
o
Veterinary Technician/Technologist
2. Military Status
Please check one of the following criteria for automatic licensure:
o
I am in active military duty stationed in Arkansas.
o
I am a returning military veteran with honorable discharge within the past twelve (12)
months.
o
I am the spouse of someone in active military duty stationed in Arkansas, or the spouse
of a returning military veteran with honorable discharge within the past twelve (12)
months.
3. Proof of Military Status
Please check one of the following and submit a copy:
o
Leave Earning Statement (LES)
o
Letter from Command
o
Copy of Orders
o
DD-214 showing “honorable discharge” (veterans)
Continue to next page
4. Evidence of Licensure
Please list below the name of the state, territory or district of the United States in which you
currently hold a substantially equivalent occupational license in good standing:
_____________________________________________
You must contact the above-listed state’s veterinary medical licensing board and request that a
license verification letter be sent directly to the Board – mail or email will be accepted.
Other Information:
o
Veterinarian:
___________________________________________________________
____/____/____
Name of Veterinary Medical School Attended
Date Graduated
OR
o
Veterinary Technician/Technologist:
___________________________________________________________
____/____/____
Name of Veterinary Technology School Attended
Date Graduated
Applicant Signature:
By submitting this application, I affirm that I have personally completed this application, and that the
information provided is true and complete to the best of my knowledge. I hereby authorize the Board to
verify all information contained in this application. My signature on this application will act as
authorization of entities in possession of applicable information to release such information to the Board.
_______________________________________________
Signature of Applicant
Date
_______________________________________________
Printed Name of Applicant
Application Submittal:
Arkansas Veterinary Medical Examining Board
1 Natural Resources Drive
Little Rock, AR 72205
For questions, please contact Cara Tharp at (501) 224-2836 or cara.tharp@agriculture.arkansas.gov.
**The application fee is waived for persons applying for Military Automatic Licensure.**
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