Form 08-609 - Application To Practice Veterinary Medicine Page 5
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14OCCUPATIONAL STATUS: List positions held for the past seven years only.
Address & Telephone
Dates & Approximate Number
Name of Employer
Number of Employer
Position Held
of Hours per Year
LICENSING DATA: List all states or jurisdictions in which you are or have been licensed to practice veterinary medicine:
1.
State
License Number
Date Issued
Expiration Date
2.
State
License Number
Date Issued
Expiration Date
REFERENCES: List four references who are doctors of veterinary medicine and who have knowledge of your character and
professional abilities. Have these four individuals complete the attached professional reference forms.
1.
Name
Address
ZIP Code
2.
Name
Address
ZIP Code
3.
Name
Address
ZIP Code
4.
Name
Address
ZIP Code
PROFESSIONAL FITNESS
If any of the following answers are YES, you must explain fully in a separate letter and attach applicable legal documentation.
YES
NO
1. Have you had a professional license denied, revoked, suspended, or otherwise restricted,
conditioned, or limited or have you surrendered a professional license, been fined, placed on
probation, reprimanded, disciplined, or entered into a settlement with a licensing authority in
connection with a professional license you have held in any jurisdiction including Alaska and
including that of any military authorities or is any such action pending?
2. Have you ever been denied a certificate, or the privilege of taking an exam by any state
Veterinary board?
3. Are you currently under investigation by another veterinary licensing authority concerning a
violation or alleged violation of any state regulations, statutes, or law, or any violation or
alleged violation of the Veterinary Practice Act, or unprofessional or unethical conduct?
4. Have you ever held a DEA registration number?
5. Have you ever surrendered or had a federal controlled substance registration revoked,
suspended, restricted, denied, or placed on probation?
6. Have you been convicted of a crime or are you currently charged with committing a crime?
For purposes of this question, “crime” includes a misdemeanor, felony, or a military offense,
including, but not limited to, driving under the influence (DUI) or driving while intoxicated (DWI),
driving without a license, reckless driving, or driving with a suspended or revoked license.
“Convicted” includes having been found guilty by verdict of a judge or jury, having entered a plea
of guilty, nolo contendere or no contest, or having been given probation, a suspended imposition
of sentence, or a fine.
08-609 (Rev. 09/23/16)
Application Page 2 of 3
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