Form 08-609 - Application To Practice Veterinary Medicine Page 11
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14State of Alaska
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
BOARD OF VETERINARY EXAMINERS
th
333 Willoughby Avenue, 9
Floor
P.O. Box 110806
Juneau, Alaska 99811-0806
Phone: (907) 465-2550
E-mail: license@alaska.gov
Website:
AFFIDAVIT OF ACTIVE PRACTICE
(for Credential Applicants)
TO BE COMPLETED BY AN INDIVIDUAL WHO HAS DIRECT PERSONAL KNOWLEDGE OF THE
APPLICANT’S PRACTICE OF VETERINARY MEDICINE
Applicants applying for a license by credentials must document active practice of veterinary medicine for at
least five of the seven years before the date of application. Active Practice means at least 1,000 hours of
practicing veterinary medicine, surgery, or dentistry during a calendar year. This document must be
submitted directly to the Division by the person completing the form.
By my signature below, I certify that
(Applicant’s Name)
has been engaged in the active practice of veterinary medicine, surgery, or dentistry for at least 1,000 hours
per
calendar year from
, to
.
month
/
year
month
/
year
I am/was associated with the applicant in the following manner:
I certify that the above information is true and correct to the best of my knowledge.
Signature
Printed Name
Title/License Number if applicable
Address
Telephone Number
SUBSCRIBED AND SWORN TO before me, a Notary Public in and for the State of
`
this
day of
,
.
Notary Public
NOTARY SEAL
My Commission Expires:
08-609b (Rev. 09/23/16)
Affidavit of Active Practice Page 1 of 1
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