Application For Verification And Examination For Licensure To Practice Veterinary Medicine In Kentucky (Page 5 of 6) in pdf

10.

Have you ever been denied the right to take a veterinarian licensure examination?

Yes

No.

Have you ever been refused a veterinarian license or the renewal therof in any state?

Yes

No.

Are you now or have you ever been a defendant in civil litigation in which the basis of the complaint against

Yes

No.

you was an alleged negligence, malpractice, or lack of professional competence?

Is there currently a complaint against your professional conduct or competence as a veterinary pending in

Yes

No.

any jurisdiction?

Have you been charged with, convicted or, or pled guilty to a felony or misdemeanor other than a minor

Yes

No.

traffic violation?

Are you now, or have you ever been, addicted to, or undergone treatment for the use of narcotics, drugs,

Yes

No.

prescription drugs or the excessive use of intoxicating liquor?

IF ANY QUESTION(S) IN SECTION 9 ABOVE IS ANSWERED YES, YOU MUST PROVIDE COMPLETE DETAILS AS TO STATE(S), LICENSE

NUMBER(S), DATE(S) AND RELEVANT CIRCUMSTANCES.

Please attach a separate sheet of paper if more space is needed to provide information.

11.

Have you ever applied to take a licensing examination in Kentucky?

Yes

No.

If answer is yes, specify date and which examination:

12.

Have you ever taken the NBE/CCT or NAVLE in any state other than Kentucky

Yes

No.

If answer is yes, specify date and which examination:

13.

Have you ever failed the NBE or CCT?

Yes

No.

If answer is yes, specify date, which examination, and state:

14.

Have you ever failed the NAVLE?

Yes

No.

If answer is yes, specify date, and state:

15.

Please list below the names, addresses and dates of employment for the last five years.

16.

Do you hereby swear or affirm that you have read and understand the Laws and Regulations relating to the Kentucky Board of Veterinary

Examiners?

Yes

No.

To complete this application, the following must be included: (a) wallet size photo(s), (b) upon graduation submit a copy of actual diploma or proof of

graduation, also (if you have not graduated, send verification that you are enrolled in a college of Veterinary Medicine and status), (c) fee for application

and examination(s), (d) your scores for the NBE and CCT or the NAVLE if already taken, must be transferred to this office from VIVA, (e) letters of good

standing from each state in which you are or have been licensed, (f) if you are requesting a special permit upon completion of your file and you have not

taken the NAVLE, you must be under the direct supervision of a Kentucky licensed veterinarian and that veterinarian must forward a letter on your behalf

stating that you will be practicing under his/her direct supervision during the period of your special permit.

YOU ARE ADVISED, YOU ARE NOT ALLOWED TO PRACTICE VETERINARY MEDICINE IN THE COMMONWEALTH OF KENTUCKY WITHOUT

HOLDING A LICENSE. THERE ARE NO EXCEPTIONS.

I hereby give permission for the Kentucky Board of Veterinary Examiners to secure additional information concerning me or any of the statements in this

application from any source the board may desire. If further agree to submit to questioning by the board or any member therof, and to substantiate my

statements if desired by the board. I further state that all the facts, statements and answers contained in this application are true and correct. I am not

omitting any information which might be of value to this board or its determination of my qualifications, whether it is requested or not and I agree that any

falsification, omission or withholding or pertinent information or facts in regard to my qualifications as an applicant shall be sufficient to bar me from this

or any future examination given by the Kentucky Board of Veterinary Examiners and any such falsification, omission or withholding shall serve as

sufficient grounds for the revocation, cancellation or suspension or my Kentucky Veterinary License.

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete, and correct and swear or affirm

that I have read the above statements and agree to the same.

Signature of Applicant

Date (month / day/ year)