Application For Courtesy Veterinary License Form

Application For Courtesy Veterinary License Form - 2000

VET

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

BOARD OF VETERINARY EXAMINERS

333 Willoughby Avenue, 9th Floor

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-5470

E-mail: license@dced.state.ak.us

APPLICATION FOR COURTESY VETERINARY LICENSE

PLEASE READ INSTRUCTIONS BEFORE COMPLETING APPLICATION.

TOTAL REQUIRED: $125.00 ($50.00 APPLICATION FEE AND $75.00 COURTESY LICENSE FEE)

Name:

Last

First

Middle Initial

Address:

Street or P.O. Box Number

City

State

Zip Code

Social Security No.:

Birth Date:

(Required by AS 08.01.060)

Daytime Telephone Number (Business, Message, Pager, etc.):

State of Residency:

All State(s) or Jurisdiction(s) Where Licensed:

State or Jurisdiction where you are currently licensed, which will forward to this office a Verification of

Licensure

Issue Date:

Expiration Date:

Special Event to Which Courtesy License will be Applied:

Sponsor’s Printed Name:

Sponsor’s Signature:

Inclusive Date License Required (30 day maximum):

Complete Address of Sponsor:

Street or P.O. Box Number

City

State

Zip Code

Sponsor Point of Contact:

Name:

Telephone Number:

Provide statement describing the scope of practice required for the event for which the courtesy license is requested:

CONTINUED ON REVERSE SIDE

08-4040 (Rev. 3/00)

Application For Courtesy Veterinary License Form - 2000

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