Veterinary Technology Form 3 - Verification Of Out-Of-State Licensure, Registration, And/or Examination December 2004 Page 2
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2SECTION II: CERTIFICATION OF LICENSURE
INSTRUCTIONS TO LICENSING AUTHORITY:
Please complete this section, sign and date the certifying statement, and return
this form in a sealed, official envelope directly to the Office of the Professions at the address at the end of this form. This form will not
be accepted if returned by the applicant.
1.
Name of applicant: ________________________________________________________________________________________
2.
Profession in which applicant is licensed in your jurisdiction: _______________________________________________________
3.
License number: __________________________________________________ Date of Licensure: ________________________
4.
On what basis was applicant licensed:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5.
Are charges pending against the licensee for professional misconduct, unprofessional conduct, incompetence or negligence or has
the licensee ever been found guilty of such charges or surrendered a professional license?
Yes
No
6.
Please specify the state, national and/or regional examinations completed by the applicant: ______________________________
_______________________________________________________________________________________________________
If the applicant was licensed in the United States via a state constructed examination, other than the Veterinary Technician
National Examination, please complete the following (list the examination subjects in chronological order by date taken):
Minimum
Date of Examination
Title/Subject
Grade
Passing Grade
CERTIFICATION
I certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the individual named
on this form.
Signature ____________________________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Print name __________________________________________________________________
Title ________________________________________________________________________
Agency
(SEAL OF LICENSING AUTHORITY)
_______________________________________________________________________________
Address ____________________________________________________________________
____________________________________________________________________
Telephone _______________________________ Fax _______________________________
E-mail: _____________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Veterinary Technology
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Veterinary Technician Form 3, Page 2 of 2, Rev. 12/04
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