Veterinary Medicine Form 3 - Verification Of Out-Of-State Licensure, Registration, And/or Examination April 2004 Page 2
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2SECTION II: CERTIFICATION OF VETERINARY MEDICINE LICENSURE
(Please print all information)
INSTRUCTIONS TO LICENSING AUTHORITY:
Please complete this section, sign and return the form directly to the Office of the
Professions at the address at the bottom of this page. This form will not be accepted if returned by the applicant.
1.
Name of Applicant: ________________________________________________________________________________________
(First)
(Middle)
(Last)
2.
Original Veterinary Medical License Number: _______________________________ Date of Licensure: ______ / ______ / ______
mo.
day
yr.
3.
Exact title under which applicant was licensed: __________________________________________________________________
4.
Basis of licensure:
written examination
other (Specify) _____________________________________
5.
If licensed by examination indicate language of examination:
English
Other (Specify) _______________________
6.
If licensed or certified by written examination, please submit a copy of that examination to the State Board for Veterinary Medicine.
The examination will be maintained in a secure status and returned after review. Such review is necessary if the applicant is to be
considered for licensure without taking the New York State required examination.
7.
Length of examination (number of questions): ____________________
8.
Raw score received by applicant: _____________________________
9.
Grade received by applicant: _________________________________
10. Passpoint and method of derivation: ___________________________________________________________________________
________________________________________________________________________________________________________
11. Name of company preparing examination: ______________________________________________________________________
12. If veterinarian was licensed or certified without examination, please explain: ___________________________________________
________________________________________________________________________________________________________
13. Was there ever any disciplinary action against this license?
Yes
No
If so, please explain: ______________________________________________________________________________________
________________________________________________________________________________________________________
14. Are there any disciplinary charges pending against this license?
Yes
No
If so, please explain: ______________________________________________________________________________________
________________________________________________________________________________________________________
CERTIFICATION
I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the veterinarian named on this form. I
further certify that, other then those listed above, this Licensing Authority has never taken any disciplinary action against this person and
that in so far as the Licensing Authority has knowledge there have been no charges preferred or sustained except as noted in questions 13
and 14 above.
Signature ________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Print name _______________________________________________
Agency __________________________________________________
Address _________________________________________________
(SEAL of LICENSING AUTHORITY)
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, NY 12234-1000
April 2004
FORM 3, Page 2 of 2
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