Veterinary Medicine Form 5 - Application For Limited Permit
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1
2The University of the State of New York
Department Use Only
Veterinarian Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
APPLICANT INSTRUCTIONS
1.
Limited permit fee in veterinary medicine is $105.00.
2.
If you have already filed the application for veterinary medicine licensure (Form 1), all required
verifications, and paid the fee, you need only submit the Form 5 and required additional fee for a
Date Approved/Rejected
Limited Permit at this time. If you have not yet filed Form 1 and all the required verifications, you must
do so before your Limited Permit application can be evaluated.
3.
Complete Section I of this form and send it to the supervising veterinarian who will supervise your
Permit number
work under the limited permit.
1
Check what you are applying for:
Date issued
75
$105
PR
Original
75
$105
PR
Renewal
Date expires
2
Social Security Number
Initials
(Leave this blank if you do not have a U.S. Social Security Number)
3
Month
Birth Date
Day
Year
6
Telephone/E-Mail Address
4
Print Name
Daytime Phone
Last
First
Area Code
Phone Number
Middle
E-Mail Address (Please print clearly)
5
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
7
WORK LOCATION(S):
Office Name: _____________________________________________________________________________________________
Office Address: ___________________________________________________________________________________________
Office Name: ____________________________________________________________________________________________
Office Address: ___________________________________________________________________________________________
Veterinarian Form 5, Page 1 of 2, Rev. 6/16
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