Form 08-609 - Application To Practice Veterinary Medicine Page 9
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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:
PROFESSIONAL REFERENCE
The information below must be completed by a professional reference. It may not be completed by the applicant. This
document must be submitted directly to the Division by the professional giving the reference.
I do certify that I have been professionally associated with
(Name of Applicant)
from
, to
.
month
/
year
month
/
year
Personal Statement:
I can personally attest that this applicant is professionally competent, reliable, worthy of confidence, and has clinical
skills, as reflected in the following statement.
PROFESSIONAL STATEMENT (REQUIRED):
I have some concern about the applicant’s professional competence, reliability, being worthy of confidence, and their
clinical skills, as reflected in the following statement.
PROFESSIONAL STATEMENT (REQUIRED):
I do not have sufficient experience with this applicant to establish their professional capabilities.
Signature
Printed Name
Title
License No.
Address
Telephone No.
SUBSCRIBED AND SWORN before me, a Notary Public in and for the State of
,
this
day of
,
.
NOTARY SEAL
Notary Public
My Commission Expires:
08-609a (Rev. 09/23/16)
Professional Reference Page 1 of 1
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