Veterinary Medicine Licensure Application - Massachusetts Division Of Professional Licensure Page 7
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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
P
E
R
F
ROFESSIONAL AND
THICAL
EFERENCE
ORM
I, ____________________________, hereby authorize ___________________________,
(applicant)
(licensed veterinarian)
to provide the Board of Registration in Veterinary Medicine with all information of any kind
which the veterinarian may deem relevant to my qualifications as an applicant. I hereby
release and discharge the endorser from all claims arising out of the provision of such
information.
Date: ___________________ Applicant’s Signature: ________________________
The remainder of this form is to be completed by the licensed veterinarian named above.
Failure to do so will render this document invalid. Do not complete unless the above waiver is
signed. This form must be signed by a Notary Public.
1. Name: ________________________________________________________________
2. Address: ______________________________________________________________
3. Tel. Number: ____________ 4. License Number: ______ 5. State where licensed:___
6. Relationship to the applicant (supervisor, professor, etc.):________________________
7: Length of time known: From _____________________ to ______________________
(month/year)
(month/year)
8. Indicate the setting(s) in which you have known the applicant, description of applicant’s
duties, and extent of your contact with applicant. ________________________________
_______________________________________________________________________
_______________________________________________________________________
9. Do you certify that the applicant is of good moral character? Yes _______ No ______
(continued)
VT App September 2017
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