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

14. Have you taken either 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 G.L. c. 62C, s. 49A, I have filed all Massachusetts tax returns and paid all Massachusetts taxes

required by law. YES ________ NO _________ If “NO” please explain: ____________________________

_____________________________________________________________________________________

(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 currently licensed veterinarians who will be completing the Professional and Ethical

Reference Forms:

__________________________________________________

18. AFFIDAVIT

I certify that I agree to abide by the G.L. 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

VT App September 2017

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