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Veterinary Medicine Licensure Application - Massachusetts Division Of Professional Licensure Page 5

DISCIPLINARY HISTORY

If you answer YES to any of the following questions (A-F), please attach a complete explanation.

A. Has any disciplinary actions been taken against you by a licensing/certification board located in the

United States or any country or foreign jurisdiction? YES

B. Are you the subject of pending disciplinary action by a licensing/certification board located in the

United States or any country or foreign jurisdiction? YES

C. Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification

board in the United States or any country or foreign jurisdiction? YES

_ NO

D. Have you ever applied for and been denied a professional license in the United States or any country or

foreign jurisdiction? YES

E. Has your registration/license to dispense controlled substances ever been suspended, revoked, or placed

on probation?

YES

F. Have you ever been convicted of a felony or misdemeanor in the United States or any country or foreign

jurisdiction, other than a traffic violation for which a fine of less than $100.00 was assessed?

YES

The Board is certified by the Criminal History Systems Board [ID# MAREG G] to access data about convictions

and pending criminal cases. Those records-and other Federal and professional records-may be checked as part of

your licensing process. No records are automatic disqualifiers; you will be given an opportunity to discuss any

issues with the Board.

10. List any professional licenses/registrations you hold or have held in the United States or any country or

foreign jurisdiction and the state/jurisdiction from which the license/registration was issued along with the

license number.

11. List all addresses where you have engaged in the practice of veterinary medicine, including service in the

armed services.

12. If you are presently engaged in any type of veterinary endeavor either as a principal or as an assistant, please

provide details.

13. Application Deadlines and NAVLE exam dates:

(Please indicate which testing window you are applying for OR that you have already tested.)



November 16 – December 12, 2015

August 1, 2015 DEADLINE:

testing window



December 20, 2015 DEADLINE

April 11 - 23, 2016

testingwindow



Already passed NAVLE

Updated 2/2015

Veterinary Medicine Licensure Application - Massachusetts Division Of Professional Licensure Page 5