"Application for Arkansas Veterinary Licensure" - Arkansas

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

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APPLICATION FOR ARKANSAS VETERINARY LICENSURE
INSTRUCTIONS:
1. Applications must be received no later than thirty (30) days prior to the State Board
Examination (NAVLE applicants – applications must be received no later than August 1 for
the November-December NAVLE and February 1 for the April NAVLE).
2. Type or print legibly with black or blue ink only.
3. The application fee ($100.00) must accompany this form and is nonrefundable.
4. Complete each section fully. If a question does not apply to you, indicate with “N/A”.
5. Use a separate sheet of paper to respond to any question for which more space is needed.
APPLICANT STATUS:
Check one of the following:
o
Fourth year veterinary student/new graduate
o
Student or graduate of a foreign veterinary school
o
Licensed, practicing less than five (5) years
o
Licensed, practicing more than five (5) years
Check one of the following:
o
I am applying for licensure by examination.
o
I am applying for licensure by endorsement or reciprocity.
A. APPLICANT IDENTIFYING INFORMATION:
Full Name:
(
)
Last
First
Middle
Maiden
Mailing Address:
Street/P.O. Box
City
State
Zip
Business Address:
Street/P.O. Box
City
State
Zip
Phone: (______) _______________________
Business Phone: (______)____________________
Fax:
(_____)_________________________
Email: ___________________________________
Date of Birth: ______/_______/______ Age: _____ Social Security Number: ______-______-________
(Required by Ark. Code Ann. § 17-1-104)
Place of Birth: _____________________________
Male: ___ Female: ___ Race: _________________
B. EDUCATION:
PRE-VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREE EARNED
VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREE EARNED
APPLICATION FOR ARKANSAS VETERINARY LICENSURE
INSTRUCTIONS:
1. Applications must be received no later than thirty (30) days prior to the State Board
Examination (NAVLE applicants – applications must be received no later than August 1 for
the November-December NAVLE and February 1 for the April NAVLE).
2. Type or print legibly with black or blue ink only.
3. The application fee ($100.00) must accompany this form and is nonrefundable.
4. Complete each section fully. If a question does not apply to you, indicate with “N/A”.
5. Use a separate sheet of paper to respond to any question for which more space is needed.
APPLICANT STATUS:
Check one of the following:
o
Fourth year veterinary student/new graduate
o
Student or graduate of a foreign veterinary school
o
Licensed, practicing less than five (5) years
o
Licensed, practicing more than five (5) years
Check one of the following:
o
I am applying for licensure by examination.
o
I am applying for licensure by endorsement or reciprocity.
A. APPLICANT IDENTIFYING INFORMATION:
Full Name:
(
)
Last
First
Middle
Maiden
Mailing Address:
Street/P.O. Box
City
State
Zip
Business Address:
Street/P.O. Box
City
State
Zip
Phone: (______) _______________________
Business Phone: (______)____________________
Fax:
(_____)_________________________
Email: ___________________________________
Date of Birth: ______/_______/______ Age: _____ Social Security Number: ______-______-________
(Required by Ark. Code Ann. § 17-1-104)
Place of Birth: _____________________________
Male: ___ Female: ___ Race: _________________
B. EDUCATION:
PRE-VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREE EARNED
VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREE EARNED
C.
OTHER LICENSES:
List all veterinary licenses currently or previously held, whether temporary or permanent:
(A license verification must be received from each state listed below)
DOES NOT APPLY
STATE
DATE OF ISSUE
EXPIRATION DATE
LICENSE NO
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
D.
PERSONAL HISTORY INFORMATION:
1. Have you ever been denied a license to practice veterinary medicine?
NO
YES
2. Do you currently have any disciplinary investigations and/or actions
pending against you in another jurisdiction?
NO
YES
3. Has any license presently or previously held by you ever been sanctioned,
revoked, suspended, placed on probation and/or otherwise been the
subject of any disciplinary review in another state?
NO
YES
4. Have you ever been convicted of, plead guilty to, or plead nolo contendre
to a felony or misdemeanor, other than for minor traffic violations?
NO
YES
5. Have you ever had a registration issued by a controlled substance authority
revoked, suspended, limited or restricted?
NO
YES
6. Have you ever voluntarily surrendered a registration issued by a
controlled substance authority?
NO
YES
7. Have you ever voluntarily surrendered a veterinary license?
NO
YES
If you answered “YES” to any of the above questions, explain in detail on a separate sheet of paper and
attach it to this application. If you answered “YES” to #5, please submit official documents with this
application.
E.
PREVIOUS EXAM HISTORY:
1.
HAVE YOU PASSED THE NATIONAL BOARD EXAMINATION AND CLINICAL
COMPETENCY TEST?
NO
YES
(THE EXAMS GIVEN PRIOR TO APRIL 2000)
If “YES”:
STATE GIVING EXAM
DATE OF EXAM
NBE
CCT
2.
HAVE YOU PASSED THE NAVLE?
NO
YES
(THE EXAM GIVEN AFTER APRIL 2000)
If “YES”:
STATE GIVING EXAM
DATE OF EXAM
3.
HAVE YOU EVER FAILED THE NAVLE?
NO
YES
If “YES”:
STATE GIVING EXAM
DATE OF EXAM
Please arrange to have your NBE, CCT OR NAVLE scores sent to this office
through the American Association of Veterinary State Boards (www.aavsb.org).
F.
CITIZENSHIP INFORMATION:
1.
Are you a United States Citizen?
NO
YES
2.
If you answered “NO” to the above question, are you:
A resident alien
A nonimmigrant under the Immigration and Nationality Act
An alien who is paroled into the United States under 8 U.S.C.A. §1182(d)(5) for less than
one year
A foreign national not physically present in the United States
Other
Please provide documentation if you marked any of the above boxes.
G.
WORK HISTORY/PRACTICAL EXPERIENCE:
List all employment chronologically since graduation from veterinary school to the present,
beginning with your date of graduation. If you have never been employed as a veterinarian,
insert “N/A” in the first box.
DATE
NAME OF HOSPITAL
TO
FROM
OR FACILITY
ADDRESS
JOB TITLE
EMPLOYER
H.
TEMPORARY PERMIT:
A temporary permit may be issued upon request to a qualified applicant pending the state
board examination or the Board’s decision on an applicant’s request for licensure by
endorsement or reciprocity. Please do not apply for a temporary permit if you are a fourth-year
veterinary student that has not yet taken the NAVLE, or if you have not yet passed the NAVLE.
Are you requesting a Temporary Permit?
NO
YES
If “YES”, an additional fee of $50.00 (along with your application fee of $100.00 – total $150.00)
must be submitted with this application.
I.
LETTER OF RECOMMENDATION:
To be completed and signed by a licensed veterinarian. This statement must be notarized. No
practitioner is expected to sign this recommendation who does not know the applicant
personally, and who is not willing to supply additional information concerning his/her character
upon request from this Board.
This certifies that I have known __________________________________________ for
___________ years, that I personally knew him/her while he/she resided in (name of city)
______________________________________in the State of ______________________; that
he/she is of good moral and professional character, that he/she is free from habits liable to
interfere with his/her professional services; that his/her standing was good in that community
and is good in the community in which he/she now lives; that he/she is worthy of receiving a
license to practice veterinary medicine in the State of Arkansas.
SIGNATURE: _____________________________________________
PRINTED NAME: __________________________________________
ADDRESS: _______________________________________________
________________________________________________________
LICENSED UNDER THE LAWS OF: _____________________________
Subscribed and sworn before me this __________ day of
________________________________, 20________.
SEAL
______________________________________________
Notary Public
My Commission Expires: __________________________
This page may be returned separately from the rest of the application
if it needs to be sent to someone to have signed and notarized.