Veterinary Medicine Licensure Application - Massachusetts Division Of Professional Licensure Page 4
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12The Commonwealth of Massachusetts
Division of Professional Licensure
Board of Registration of Veterinary Medicine
1000 Washington Street, Suite 710
Boston, MA 02118-6100
Phone: (617) 727-5899
Please attach recent passport type
2” x 2”
head and shoulder photograph
VETERINARY MEDICINE
LICENSURE APPLICATION
{NON-REFUNDABLE APPLICATION AND JURISPRUDENCE EXAM FEE $272.00}
1. Name:
Last
First
Middle
Maiden
2. Mailing Address(this will be public record):
No.
Street
Apt. No.
City/Town
State
Zip Code
3. Date of Birth:
Place of Birth:
month/ day/ year
4. Telephone Number (Day):
(Eve.):
5. E-mail address:
Name of Veterinary School:
6.
7. Date and Degree Conferred:
8. CERTIFICATE BY DEAN OR REGISTRAR OF VETERINARY COLLEGE
(If Requesting Examination Prior to Degree Conferral)
I,
, as Dean/Registrar of
certify that the applicant attended this institution from
to
_ and has received or
will receive (circle one) a Doctor of Veterinary Medicine degree on
.
S
S
CHOOL
EAL
Signature of Dean/Registrar
Updated 2/2015
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