Form 08-609 - Application To Practice Veterinary Medicine (Page 6 of 14) in pdf

Form 08-609 - Application To Practice Veterinary Medicine Page 6

PROFESSIONAL FITNESS CONTINUED:

YES

7. Within the past five years, have you been or are you addicted to, excessively used, or misused,

alcohol, narcotics, barbiturates, or habit forming drugs?

8. Within the past five years have you experienced or been treated for, bipolar disorder,

schizophrenia, paranoia, depression (except for situational or reactive depression), psychotic

disorder, or other mental or physical condition or disability?

The contents of licensing files are generally considered public records. If you believe that the additional information you are

attaching to explain a “yes” answer should be considered confidential, state that in the attachment. A request for

confidentiality may or may not be granted.

I attest that all 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 in determining my qualifications and character, whether it is called for or

not. Such falsification, omissions, or withholding shall serve as sufficient grounds for the suspension, cancellation, or

revocation of my veterinarian license even though it is not discovered until after issuance.

I have read the Alaska Veterinary Practice Act. I solemnly declare upon my honor that, if granted a license in Alaska, I

will respectfully comply with any law governing the practice of veterinarians in this state, and will do my best to uphold

and maintain the ethics of the profession.

By my signature below, I CERTIFY that all information furnished in this publication is true and correct. I

understand that it is a Class A misdemeanor under Alaska Statute 11.56.210 to falsify an application and commit

the crime of unsworn falsification.

SIGN HERE

Signature of Applicant

Date

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:

08-609 (Rev. 09/23/16)

Application Page 3 of 3

Form 08-609 - Application To Practice Veterinary Medicine Page 6