Veterinary Technology Form 5 - Application For Limited Permit
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1
2The University of the State of New York
Department Use Only
Veterinary Technician Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
1
76
$50
PR
APPLICANT INSTRUCTIONS
Permit number
1.
The fee for a limited permit in veterinary technology is $50.00. Be sure to sign and date item 9.
2.
If you have already filed the Application for Licensure (Form 1) and all required verifications, you need
Date issued
only submit the Form 5 and required fee for a limited permit at this time. If you have not yet filed Form
1, paid the fee and submitted all the required verifications, you must do so before your limited permit
application can be evaluated.
Date expires
Complete Section I of this form in ink and send it to the supervising veterinarian who will supervise
3.
your work under the limited permit. Return the completed form with your limited permit fee to the
Initials
Office of the Professions at the address at the end of this form.
2
6
Telephone/E-Mail Address
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Daytime Phone
3
Birth Date
Month
Day
Year
Area Code
Phone Number
4
Print Your Full Name Exactly as it Appears On Your Licensure Application Form (Form 1)
Last
E-Mail Address (Please print clearly)
First
Middle
7
I am applying for:
Mailing Address (You must notify the Department promptly of any address or name changes.)
5
Original permit
Line 1
Extension of original permit
Line 2
Additional site or supervisor
(No fee required)
Line 3
Change in site or supervisor
City
(No fee required)
State
Zip Code
Country/
Province
8
WORK LOCATION(S):
Office name: _____________________________________________________________________________________________
Office address: ___________________________________________________________________________________________
Office name: _____________________________________________________________________________________________
Office address: ___________________________________________________________________________________________
9
ATTESTATION
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I
understand that any false or misleading information in, or in connection with, my application may be cause for denial of permit and licensure and
may result in criminal prosecution.
Applicant's signature: ________________________________________________________ Date _______ / ________ / _______
mo.
day
yr.
Veterinary Technician Form 5, Page 1 of 2, Rev. 6/16
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