Form Doh 672-033 - Veterinary License Application Packet Page 9
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
152. Personal Data Questions (cont.)
Yes No
6. Have you ever been found in any civil, administrative or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes? ...................................................F F
b. Diverted controlled substances or legend drugs? ................................................................................F F
c. Violated any drug law? .........................................................................................................................F F
d. Prescribed controlled substances for yourself? ....................................................................................F F
7. Have you ever been found in any proceeding to have violated any state or federal law or rule
regulating the practice of a health care profession? If “yes”, please attach an explanation and
provide copies of all judgments, decisions, and agreements? . ...............................................................F F
8. Have you ever had any license, certificate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ..............F F
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to
avoid action by a state, federal, or foreign authority? ...............................................................................F F
10. Have you ever been named in any civil suit or suffered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession? .........................F F
11. Have you ever been disqualified from working with vulnerable persons by the Department
of Social and Health Services (DSHS)? .................................................................................................. F F
4. Professional Education
List in date order your educational preparation and post-graduate training.
Attendance
Full name, city and state of schools attended
Degree earned
Entrance date
Ending date
DOH 672-001 August 2016
Page 3 of 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business