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Veterinary Medicine Form 2ct - Certification Of Clinical Training - New York The State Education Department Page 2

SECTION II: CERTIFICATION OF CLINICAL TRAINING

INSTRUCTIONS TO VETERINARY HOSPITAL/CLINIC: Please complete items 1, 2, and 3, sign the certifying statement (item 4) and

send directly to the Office of the Professions at the address at the bottom of this page. The form will not be accepted if returned by the

applicant or any other party.

This is to certify that ________________________________________________________________, as a student of

(student's name)

__________________________________________________________________, participated in a clinical training program offered

(veterinary school)

by __________________________________________________________ from ______________ through ______________ in the

(hospital/clinic name)

(date)

clinical area of _______________________________________________________________ and that the above named student

(clinical area)

successfully completed this clinical experience of ______________ weeks on ______________

(date)

This hospital/clinic (check all that apply):

is formally affiliated with the student's veterinary school

is formally affiliated with an AVMA approved veterinary school

other (explain)

_______________________________________________________________________________________________________

I served as (check one):

director of training program

individual instructor or supervisor for above named student

other (please state your current capacity) _____________________________________________________________

________________________________________________________________________________________________

This training conforms to provisions of statute and regulations in ______________________________ at the time training was completed.

(State)

(Attach more information if needed to explain clinical training)

I certify that the information provided is true and correct according to our records.

Signature: ________________________________________________ Date: ___________________________

Name and title: ____________________________________________

(type or print)

____________________________________________

(SEAL of INSTITUTION)

Address: _________________________________________________

_________________________________________________

Telephone: ________________________________________________

Fax: ________________________ E-mail: _______________________

RETURN DIRECTLY TO:

New York State Education Department, Office of the Professions, Division of Professional Licensing

Services, Veterinary Medicine Unit, 89 Washington Avenue, Albany, New York 12234-1000.

April 2004

Form 2CT, Page 2 of 2

Veterinary Medicine Form 2ct - Certification Of Clinical Training - New York The State Education Department Page 2