Veterinary Technology Form 5 - Application For Limited Permit Page 2
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2CITIZENSHIP/IMMIGRATION STATUS:
9
Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses, registrations
and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you must complete
this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
I am:
A.
A United States citizen or National.
B.
An alien lawfully admitted for permanent residence in the United States.
C.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E.
An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
F.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
H.
Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to
have a Visa to enter the United States: _______________________________________
I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar
relief from deportation. Please specify: _______________________________________
J.
I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and
Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD
BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283, OR VISIT THEIR WEB SITE
AT
SECTION II: CERTIFICATION OF SUPERVISOR
INSTRUCTIONS TO SUPERVISING VETERINARIAN
By completing the information in Section II of this form, the supervisor is certifying that the applicant named in Section I will be employed under the supervision of a
licensed veterinarian who is currently registered in New York State and that the supervisor agrees to abide by the conditions stipulated on the permit.
1.
A limited permit shall expire one year from the date of issuance or until the permittee has had the opportunity to take the licensing examination and receive the
results, whichever occurs first.
2.
The applicant may not be employed until the limited permit is issued.
3.
Complete Section II of this form. Sign and date the certification and return the form to the applicant for submission to the Office of the Professions.
1.
Applicant's name: _________________________________________________________________________________
2.
Name of supervising veterinarian: ____________________________________________________________________
(Please print)
3.
License number: ___________________________
4.
Office name: _____________________________________________________________________________________
5.
Office address:
_______________________________________________________________________________
(Street)
_______________________________________________________________________________
(City)
(State)
(Zip code)
6.
Telephone Number: ( _______ ) __________________ Fax: ____________________ E-mail: ____________________
CERTIFICATION
I certify that the applicant named in Section I will be employed under the supervision of a New York State licensed currently registered
veterinarian and that the supervisor agrees to abide by the conditions stipulated on the permit.
I declare that the statements made in the foregoing certification are true, complete and correct. Any false or misleading information in or in
connection with this certification would be professional misconduct and may be cause for disciplinary action against my professional license.
Signature: __________________________________________________________
Date: __________ / __________ / __________
(Supervising veterinarian)
mo.
day
yr.
Title: ______________________________________________________________
Telephone: __________________ Fax: __________________
Print name: _________________________________________________________
E-mail: ____________________________________________
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,
NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Veterinary Technician Form 5, Page 2 of 2, Rev. 6/16
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