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 in 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
Signature of Dean/Registrar
CHOOL
EAL
VT App September 2017
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