Form 08-609 - Application To Practice Veterinary Medicine Page 14
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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:
STATEMENT OF SUPERVISION
(Only to be used if applying for a temporary license while awaiting state jurisprudence examination results)
Date:
To Board of Veterinary Examiners:
I,
, am willing to assume the full responsibility of supervising
who is submitting an application for examination in the practice of
veterinary medicine. The supervision will take place at:
Name and Address of Practice
This supervision will be held in compliance with the statutes and regulations set forth by the Board of Veterinary Examiners.
I understand that the above-named applicant must work under my direct supervision and within my physical presence. I further
understand that the temporary license is valid until the results of the examination for which the applicant is scheduled are
published and that the temporary license is nonrenewable.
I certify that the above information is true and correct.
Signature of Sponsoring Veterinarian
Alaska License No.
08-609d (Rev. 09/23/16)
Statement of Supervision Page 1 of 1
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