Application For Verification And Examination For Licensure To Practice Veterinary Medicine In Kentucky Page 3
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B
V
E
ENTUCKY
OARD OF
ETERINARY
XAMINERS
P.O. Box 1360, Frankfort, Kentucky 40601 ~ 911 Leawood Drive, Frankfort, Kentucky 40601
(502)564-3296 ~
APPLICATION FOR VERIFICATION AND EXAMINATION FOR LICENSURE
TO PRACTICE VETERINARY MEDICINE IN KENTUCKY
Check applicable box(es):
BOARD USE ONLY
Applying to take the NAVLE: Nov-Dec.20__
April 20__
Other:
Approved
Denied
KY State Board Examination
Fee: $100.00
Date Issued:
Application fee (Must be attached)
Fee: $100.00
Special Permit (only for NAVLE Applicants)
Fee: $50.00
License Number:
NBE and/or CCT, or NAVLE Score is being
transferred to the Kentucky Board from VIVA.
All items on this application are mandatory. You must answer fully and completely all questions contained on this
SS#
application. Insufficient answers or omissions of data requested will be sufficient grounds for rejection of this
-
-
application.
1. Full Name:
Last
First
Middle
2. Birthday / Month / Day/ Year/
3. Mailing Address: Number and Street
City
State
Zip Code
Home Phone Number
(
)
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4. Permanent Residence Address:
City
State
Zip Code
Business Phone Number
(
)
-
5. E-mail address:
Date(s) for Name Change(s)
6. Have you ever changed your name through marriage or through action of a court, or have you ever been known
by any other name:
Yes
No. If yes, List Names:
7.
Veterinary College or University
Dates Attended
Course
Degree
School
Name and Location
From
To
Obtained
8.
In what other states do you hold or have you held a license? Written certification of license status from those state boards is required.
State
License Number
Date Issued
How did you obtain
Status of License
Period of Practice
this license?
9.
A.
Have you ever had your license to practice veterinary medicine revoked, suspended, restricted, or denied in any state or territory, been
placed on probation, or entered into a voluntary surrender of your license?
Yes
No. If your answer is yes, please specify state,
date, charge and circumstances and submit formal documentation of final orders/outcome (if applicable.)
B.
Has any disciplinary action ever been taken against a veterinary license held by you, in this or any other jurisdiction?
Yes
No. If
yes, please specify state, date, charge, and circumstances and submit formal documentation of final orders/outcome. (if applicable)
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