"Corporate Practice Application" - Arkansas

Corporate Practice 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 Department of Agriculture
Veterinary Medical Examining Board
1 Natural Resources Drive
Little Rock, AR 72205
(501) 224-2836
CORPORATE PRACTICE APPLICATION
In compliance with rules adopted by the Arkansas Veterinary Medical Examining Board (Board) –
“Corporations”: The standard professional title for a corporate veterinary practice shall be as required by the
Professional Corporation Act. Veterinary practices may be by sole practitioners, partnerships or duly registered
corporations. Only licensees may be partners. No corporation may practice or offer to practice unless it holds a
current certificate from the Board.
INSTRUCTIONS: Complete this form and retain a copy for your records. Mail (1) the original application
form (2) a copy of the filed Articles of Incorporation and (3) the $35.00 application fee to the Board
office.
List the name and address of the corporation as identified on the Articles of Incorporation:
Name of Corporation: _______________________________________________________________________
Mailing Address: ___________________________________________________________________________
(Street/P.O. Box)
(City)
(State)
(Zip)
List below the name and Arkansas license number of all veterinarians who are incorporators, officers, directors
or shareholders of the above-named corporation:
NAME
LICENSE NUMBER
1.
__________________________________________________
_______
2.
__________________________________________________
_______
3.
__________________________________________________
_______
(Please use a separate sheet of paper if you need to list additional names.)
I hereby certify that the information on this application is true and correct to the best of my knowledge.
____________________________________________
______________________________
Applicant’s Signature
Date
For Board Use Only:
Received By: __________________________ Date: ___________
Arkansas Department of Agriculture
Veterinary Medical Examining Board
1 Natural Resources Drive
Little Rock, AR 72205
(501) 224-2836
CORPORATE PRACTICE APPLICATION
In compliance with rules adopted by the Arkansas Veterinary Medical Examining Board (Board) –
“Corporations”: The standard professional title for a corporate veterinary practice shall be as required by the
Professional Corporation Act. Veterinary practices may be by sole practitioners, partnerships or duly registered
corporations. Only licensees may be partners. No corporation may practice or offer to practice unless it holds a
current certificate from the Board.
INSTRUCTIONS: Complete this form and retain a copy for your records. Mail (1) the original application
form (2) a copy of the filed Articles of Incorporation and (3) the $35.00 application fee to the Board
office.
List the name and address of the corporation as identified on the Articles of Incorporation:
Name of Corporation: _______________________________________________________________________
Mailing Address: ___________________________________________________________________________
(Street/P.O. Box)
(City)
(State)
(Zip)
List below the name and Arkansas license number of all veterinarians who are incorporators, officers, directors
or shareholders of the above-named corporation:
NAME
LICENSE NUMBER
1.
__________________________________________________
_______
2.
__________________________________________________
_______
3.
__________________________________________________
_______
(Please use a separate sheet of paper if you need to list additional names.)
I hereby certify that the information on this application is true and correct to the best of my knowledge.
____________________________________________
______________________________
Applicant’s Signature
Date
For Board Use Only:
Received By: __________________________ Date: ___________