"Application Form for Arkansas Veterinary Licensure" - Arkansas

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

Form Details:

  • Released on May 1, 2017;
  • The latest edition currently provided by the Arkansas Veterinary Medical Examining Board;
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APPLICATION FOR ARKANSAS VETERINARY LICENSURE
INSTRUCTIONS:
Applications must be received no later than 30 days prior to the Written 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).
Type or print legibly with black or blue ink only.
The application fee ($100.00) must accompany this form and is nonrefundable.
Complete each section fully. If a question does not apply to you, indicate with “N/A”.
DO NOT LEAVE ANY BLANKS.
Use a separate sheet of paper to respond to any question for which more space is
needed.
APPLICANT STATUS:
Fourth Year Student or New Graduate
Licensed practicing less than 5 years
Student or Graduate of Foreign
Licensed practicing more than 5 years
Veterinary School
I am applying for licensure by:
EXAMINATION
POULTRY SPECIALTY
ENDORSEMENT
A. APPLICANT IDENTIFYING INFORMATION:
FULL LEGAL 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 ADDRESS: ________ ________________________
DATE OF BIRTH: ______/_______/______ AGE: ____
SOCIAL SECURITY NUMBER: _________-_______-_________
(Required Under Ark. Code Ann. §17-1-104)
PLACE OF BIRTH: ____________________________________
MALE: ______ FEMALE: ______ RACE: __________________
B. EDUCATION:
PRE-VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREES EARNED
VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREES EARNED
SUBMIT COPY OF DIPLOMA FROM VETERINARY COLLEGE
(8-1/2 x 11” copy preferred)
APPLICATION FOR ARKANSAS VETERINARY LICENSURE
INSTRUCTIONS:
Applications must be received no later than 30 days prior to the Written 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).
Type or print legibly with black or blue ink only.
The application fee ($100.00) must accompany this form and is nonrefundable.
Complete each section fully. If a question does not apply to you, indicate with “N/A”.
DO NOT LEAVE ANY BLANKS.
Use a separate sheet of paper to respond to any question for which more space is
needed.
APPLICANT STATUS:
Fourth Year Student or New Graduate
Licensed practicing less than 5 years
Student or Graduate of Foreign
Licensed practicing more than 5 years
Veterinary School
I am applying for licensure by:
EXAMINATION
POULTRY SPECIALTY
ENDORSEMENT
A. APPLICANT IDENTIFYING INFORMATION:
FULL LEGAL 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 ADDRESS: ________ ________________________
DATE OF BIRTH: ______/_______/______ AGE: ____
SOCIAL SECURITY NUMBER: _________-_______-_________
(Required Under Ark. Code Ann. §17-1-104)
PLACE OF BIRTH: ____________________________________
MALE: ______ FEMALE: ______ RACE: __________________
B. EDUCATION:
PRE-VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREES EARNED
VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREES EARNED
SUBMIT COPY OF DIPLOMA FROM VETERINARY COLLEGE
(8-1/2 x 11” copy preferred)
C.
PREVIOUS REGISTRATION(S):
LIST ALL VETERINARY LICENSES CURRENTLY OR PREVIOUSLY HELD, WHETHER TEMPORARY OR
PERMANENT (A Verification of Licensure form must be completed by each state listed and returned to
this Board):
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 investigation(s) and/or action(s)
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, 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
If “YES”:
STATE GIVING EXAM
DATE OF EXAM
NBE
CCT
2.
HAVE YOU PASSED THE NAVLE (given after April 2000)?
NO
YES
If “YES”:
STATE GIVING EXAM
DATE OF EXAM
3. HAVE YOU EVER FAILED A LICENSING EXAMINATION?
NO
YES
If “YES”:
NAME OF EXAM
STATE GIVING EXAM
DATE OF EXAM
PLEASE ARRANGE TO HAVE YOUR NBE, CCT OR NAVLE SCORES SENT TO THIS
OFFICE VIA THE AMERICAN ASSOCIATION OF VETERINARY STATE BOARDS
(AAVSB).
WEB ADDRESS: 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:
(Please check one of the following)
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
If you checked any of the above, please provide documentation
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.
PERSONAL DATA:
Description of Applicant:
AFFIX A PHOTOGRAPH HERE
Height: __________ Weight: __________
Eye Color: _________________________
TAKEN WITHIN 6 MONTHS
Hair Color: _________________________
Date of Photo: ______________________
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: ____________________________
SEAL
Subscribed and sworn to before me this __________________
day of _____________________________, 20_______________.
_____________________________________________________
Notary Public
My Commission Expires: ________________________________