Employment Verification Form - 2000 printable pdf download

Employment Verification Form - 2000

STATE OF ALASKA

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

BOARD OF VETERINARY EXAMINERS

P.O. BOX 110806

JUNEAU, ALASKA 99811-0806

(907) 465-5470

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

EMPLOYMENT VERIFICATION

APPLICANT:

Complete only the top portion of this form. The remaining portion of this form is to be completed by

your present or former supervisor who supervised you in a veterinary facility.

, am applying for a Veterinary

(Print Name)

(Social Security Number)

Technician License and hereby authorize you to release information as required on this form.

Signature:

Employment Dates

Address:

TO THE SUPERVISING VETERINARIAN:

Please complete this form and return to the Board of Veterinary

Examiners at the above address.

1. Employee’s position:

2. Dates you supervised employee:

3. Location where you supervised employee:

4. Type of practice:

5. Approximate number of hours employee worked per week:

6. Your rating of employee’s ability:

Please provide details regarding the employee’s responsibilities. (Continue on back, if needed.)

Signature:

Title:

Printed Name:

License Number:

Place of Employment:

Date:

Address:

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for the State of

this

day of

, __

NOTARY PUBLIC

My Commission Expires:

08-4251a (Rev. 11/00)

Employment Verification Form - 2000