Application For License To Practice Veterinary Medicine, Surgery And Dentistry printable pdf download

MISSISSIPPI BOARD OF VETERINARY MEDICINE

APPLICATION

FOR

License to Practice Veterinary Medicine, Surgery and Dentistry

_________________________________________

Date

To the Mississippi Board of Veterinary Medicine:

I hereby make application for examination to be held the second Tuesday in June in Jackson, Mississippi for

license to practice Veterinary Medicine, Surgery and Veterinary Dentistry in the State of Mississippi, and herewith present

the following credentials as required by law:

- Application filled out in full

- NBE and CCT Grades or NAVLE Grades

- Copy of diploma from Veterinary College/School

from AAVSB

- The Regular Fee of Two Hundred Dollars

- Completed Certificate of Licensure in Another

($200.00)

State from every state in which you have

- Passport quality photograph (taken within the Past 6 months)

ever held a License to practice Veterinary

- Three (3) letters of recommendation.

Medicine

NOTE: Application must be submitted thirty (30) days prior to State Board Examination.

MY FULL NAME (Type or Print) _______________________________________________________________________

I was born in ______________________________________________________________________________________

on ________________________________ and am _____ years of age. My home address is______________________

_________________________________________________________________________________________________

City, Town or Post Office

State

Zip Code

County

My phone number is _________________________________and email address is___________________________

I graduated from _________________________________ and attained the Degree of ____________________________

on the _____ day of _____________________, _____. Social Security/Federal ID Number________________________

I have practiced Veterinary medicine, Veterinary Surgery and Veterinary Dentistry in the State of ____________________

___________________________from ________________________, ________ to _____________________, ________

at ______________________ my present location being ___________________________________________________.

I, __________________________ solemnly swear or affirm that the Statements on this application are true and correct. I

further swear or affirm that I have read Section 14 of the Mississippi Veterinary Practice Law of 2008 (see reverse side)

and that I am not now nor have I ever been guilty in the past of any act of unethical or improper conduct as therein listed.

________________________________________________

Signature of Applicant in Full

State of ___________________________________

County of _________________________________

This day there personally appeared before me, the undersigned authority within and for the county and state

above mentioned, the within and above named ____________________ known to me to be the same person who

executed the annexed and foregoing application, who being duly sworn by me state on his oath that the statements made

by him in the said application, specifically including the statement that he has read Section 14 of the Mississippi

Veterinary Practice Law of 2008 are true and correct as therein stated and that he executed the same freely and

voluntarily and for the uses and purposes therein mentioned.

Given under my hand and official seal of office in this the ______ day of ____________________________,

_________.

Notary Public _____________________________________

My commission expires: _____________________

CERTIFICATE OF CHARACTER

We the undersigned certify that the applicant, __________________________, whose name appears upon this

application, is a person of good moral character and if found qualified, deem him worthy to receive a license to practice

Veterinary medicine, Veterinary Surgery and Veterinary Dentistry. I further state that I am not related to the applicant.

Name _________________________________________

Name ________________________________________

Address _______________________________________

Address ______________________________________

**Signature _____________________________________

Occupation____________________________________

Name _________________________________________

Name ________________________________________

Address __________ _____________________________

Address ______________________________________

**Signature _____________________________________

Occupation____________________________________

** Must be licensed veterinarian, in good standing in Mississippi, graduate of approved college, presently be, and for the

last five years have been engaged in the practice of veterinary medicine in Mississippi, or a member of the faculty of the

College or School of Veterinary Medicine from which the applicant graduated, personally knew the applicant, and is listed

in the present AVMA Directory.

Application For License To Practice Veterinary Medicine, Surgery And Dentistry

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