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Veterinary Medicine Licensure Application - Massachusetts Division Of Professional Licensure Page 6

14. Have you taken any of the following examinations?

NBE

CCT

Candidates who have successfully taken and passed the NBE and CCT on or before April 2000 are eligible for a

license. Candidates who have passed only one of those examinations will be required to take the NAVLE.

If you have previously taken an examination, you must have your scores transferred from VIVA to the Board

of Veterinary Medicine (See instructions)

15. Pursuant to GL c 62C, s. 49A, I have filed all Massachusetts tax returns and paid all Massachusetts taxes

if “no”, please explain

required by law. YES

(If you have never been a resident of MA and therefore not required to file MA taxes check “no” and indicate

that above)

16. If you are not a graduate of a school of veterinary medicine accredited by the American Veterinary Medical

Association, have you secured a PAVE or ECFVG certificate or a Certificate of Qualification issued by the

Canadian Veterinary Medical Association?

YES

_ NO

_ IN PROCESS

N/A

Official documentation of certificate status is required from the awarding entity (see instructions)

17. Please list the two licensed veterinarians who will be completing the Professional and Ethical Reference

Forms.

18. AFFIDAVIT

I certify, that I agree to abide by the GL c. 112, s. 54-60 and the Rules and Regulations for the licensing of

veterinarians as contained in 256 CMR and attest that all statements made in herein are truthful and are made

under the pains and penalties of perjury.

Applicant’s Signature

Date

Notary Signature

Date Commission Expires

Updated 2/2015

Veterinary Medicine Licensure Application - Massachusetts Division Of Professional Licensure Page 6