Veterinary Medicine Form 3 - Verification Of Out-Of-State Licensure, Registration, And/or Examination April 2004

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The University of the State of New York
FORM 3
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
VETERINARIAN
89 Washington Avenue
Albany, NY 12234-1000
VERIFICATION OF OUT-OF-STATE LICENSURE, REGISTRATION
AND/OR EXAMINATION
APPLICANT INSTRUCTIONS
1.
Complete Section I. Enter your name as it appears on your licensure application (Form 1). Be sure to sign and date item 7.
2.
Send this form to the appropriate state, province, or country, as instructed in the "Completing the Application Forms" section of this application packet.
Be sure to include any fee required. Request that they complete Section II and send the form directly to the Office of the Professions at the address on
the bottom of page 2 of this form.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT YOUR NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
First
Middle
4
MAILING ADDRESS (
You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
If you entered a licensing examination in the United States, using a different name, enter that name below:
___________________________________________________________________________________________________________
(last)
(first)
(middle)
6
If licensed by examination in the United States, give state or territory: ____________________________________________________
Date license was issued: _____________________________________ License number: ___________________________________
7
I request and give my permission to the licensing authority to complete the information on this form and send any documentation
requested, including that listed on page 2 of this form to the New York State Education Department's Office of the Professions.
Applicant's signature:
Date:
/
/
____________________________________________________________________
_______
_______
_______
mo.
day
yr.
April 2004
CERTIFICATION OF VETERINARY MEDICINE LICENSURE IS TO BE MADE ON PAGE 2
Form 3, Page 1 of 2

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