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NOTICE OF REQUIREMENT AND USE OF SOCIAL SECURITY NUMBER

You are required to provide your Social Security Number (SSN) on this application. THIS IS MANDATORY. Authority for this requirement

is ORS 25.785, ORS 305.385, 42USC § (405)(c)(2)(C)(i) and 42 USC § 666(a)(13). Failure to provide your SSN will be a basis to refuse

to issue or renew the license. This record of your SSN will be used for child support enforcement and tax administration purposes

(including identification) only unless you authorize other uses. Although a number other than your SSN appears on the face of the

veterinary license, your SSN will remain on file with the Veterinary Medical Examining Board.

YOU MUST ANSWER THE FOLLOWING QUESTIONS

Explain ‘yes’ answers to questions 1-4 and a ‘no’ answer to question on a separate sheet. Failure to provide explanations

or to be truthful may result in denial of licensure. A ‘yes’ answer does not preclude licensure. The Board will review

applications with exceptional circumstances on an individual basis and decide on the facts. If your application is denied,

you have the right to a fair hearing to appeal the denial.

1. Have you ever been arrested, charged or convicted of a felony or misdemeanor?

Yes

No

2. Have you ever been treated for controlled substance or alcohol abuse?

Yes

No

3. Have you ever had a veterinary or other professional license suspended or revoked,

Yes

No

or had other disciplinary action taken against you in any other state or country?

4. Are there any other facts not disclosed by your previous answers which might bear adversely

Yes

No

on your eligibility and competence to practice veterinary medicine?

5. Do you agree that if there are other matter(s) which occur hereafter before you receive your

Yes

No

license as a veterinarian, which might adversely bear on your eligibility to practice veterinary medicine,

such matter(s) will be disclosed by you immediately to the Oregon Veterinary Medical Examining Board?

Sign and

Make $75 check or money order payable to

date a

OVMEB and mail to:

current

photo

Veterinary Medical Examining Board

and

800 NE Oregon St., Ste. 407

attach

Portland, OR 97232



here

NOTARY PUBLIC:

In the State of ____________________, County of________________________

Subscribed and sworn to before me this ______ day of _____________, 200___

(SEAL)

Signed: __________________________________________________________

Notary Public for _______________________________

County Commission Expires: _____________________

PLEASE NOTE:

You may not practice veterinary medicine in Oregon until you have received your license or permit unless you are already

licensed in another state and are working in consultation with a licensed Oregon veterinarian for 30 days or less (ORS 686.040(8). When you have

completed the application process, including passing the Juris Prudence exam, a license or permit activation form will be sent to you. You may

download forms at our website,

AFFADAVIT OF APPLICANT: I, ___________________________________________, depose and say that all of the

preceding statements are true and correct, that I am the person described and identified above and on all attached

documents, and that I will not practice veterinary medicine in Oregon until my license or permit has been issued.

Signature of applicant:_____________________________________________________ Date _____________________

Veterinary License Or Intern License Application - Oregon Veterinary Medical Examining Board Page 4

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