Application For Courtesy Veterinary License Form

Foreign Veterinary Graduates:

Have you successfully passed the examination of the Education Commission for Foreign Veterinary Graduates.

YES

If NO, you must complete the statement below:

, agree to practice only under the direct supervision of

, License No.

, who holds a

Veterinarian

permanent license in this state or who holds a permanent license in another state and a courtesy license in this state.

Signature of Applicant

Clinic:

Are you an AVMA board certified specialist?

YES

Specialty:

Verification of current status as a specialist certified by the American Veterinary Medical Association (AVMA) is required for

the specialty area for which you are requesting a courtesy license.

ALL APPLICANTS: In accordance with 12 AAC 68.041(8)(A)(B) and (C), I attest that I have not:

had a veterinary license suspended or revoked in any jurisdiction;

been convicted, by a civilian court of this state, the United States, or another state or territory of a felony or misdemeanor

involving alcohol or a controlled substance listed in AS 11.71.140 - AS 11.71.190 within the three years immediately

before the date of application for a courtesy license; and

had two or more repeat convictions, by a civilian court of this state, the United States, or another state or territory of a

felony or misdemeanor involving alcohol or a controlled substance listed in AS 11.71.140 - AS 11.71.190 within the five

years immediately before the date of application for a courtesy license, unless the applicant has also successfully

completed a treatment program related to abuse of alcohol or a controlled substance since the date of the most recent

conviction.

Signature of Applicant:

Date:

All information on this form and supplied with this form will be available to the public, unless required to be kept confidential by state

or federal law.

Subject to the penalties of unsworn falsification as defined in AS 11.56.210, I

, the applicant herein, state that all facts, statements, and answers

contained in this application are true and correct; I am not omitting any information which might be of value to this board in

determining my qualifications and character, whether it is called for or not. Such falsifications, omissions, or withholding shall serve

as sufficient grounds for the suspension, cancellation, or revocation of my veterinarian courtesy license even though it is not

discovered until after issuance.

I hereby give permission to the Board of Veterinary Examiners to secure additional information concerning me or any statement in

this application from any person or any source the board may desire. I further agree to submit to questioning by the board or any

member thereof, and to substantiate any statements if desired by the board.

I have read the Alaska Veterinary Practice Act. I solemnly declare upon my honor that, if granted a courtesy license in Alaska, I will

respectfully comply with any law governing the practice of veterinarians in this state, and will do my best to uphold and maintain the

ethics of the profession.

Signature of Applicant

SUBSCRIBED AND SWORN to before me this

day of

, 20

Notary Public

08-4040 (Rev. 3/00)

My Commission Expires:

Application For Courtesy Veterinary License Form - 2000 Page 2

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