Veterinary Medicine Form 5 - Application For Limited Permit Page 2
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2CITIZENSHIP/IMMIGRATION STATUS:
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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
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct.
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I understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure
and result in criminal prosecution.
Applicant's signature: __________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
SECTION II: CERTIFICATION OF SUPERVISOR
INSTRUCTIONS TO SUPERVISING VETERINARIAN
By completing the information in Section II of the form, the supervisor is certifying that the permittee named in Section I will be employed under the supervision of a licensed
veterinarian who is 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 upon notice to the applicant by the Department that the application for licensure has been denied or that
the applicant has failed a part of the licensure examination.
2.
The applicant may not be employed until the limited permit is issued.
3.
Complete Section II of this form, signing the attestation below.
1.
Name of supervising veterinarian: ___________________________________________________________________________
(PLEASE PRINT)
2.
License number: ___________________________
3.
Office name: ____________________________________________________________________________________________
4.
Office address:
_____________________________________________________________________________________
(Street)
_____________________________________________________________________________________
(City)
(State)
(Zip Code)
5.
Telephone number: _________________________ Fax: _______________________ E-mail: ___________________________
6.
Applicant's name: _______________________________________________________________________________________
I certify that the individual named in Section I will be employed under the supervision of a currently registered New York State licensed
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 _______ / _______ / _______
mo.
day
yr.
(Supervising Veterinarian)
Title: ______________________________________________________________
Print name: _________________________________________________________
RETURN WITH 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.
Veterinarian Form 5, Page 2 of 2, Rev. 6/16
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