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Veterinary License Or Intern License Application - Oregon Veterinary Medical Examining Board Page 5

Oregon Veterinary Medical Examining Board

800 N.E. Oregon St., Suite 407

Portland, Oregon 97232

Phone: 971-673-0224

Fax: 971-673-0226

VERIFICATION OF EXPERIENCE

_______________________________________________________

Applicant Name:

(please print)

Applicants for a permanent active Oregon veterinary license must have at least one year of

experience in another state, province or territory of the U.S. or one year of supervised experience

(internship) in Oregon. This must be verified by a licensed veterinarian employer or colleague with

knowledge of applicant’s experience. Use a separate form (copy this original) for each veterinarian

verifying experience. A signed letter with similar statements may be accepted in lieu of this form.

Return form with original signature to address above. Form may be faxed if original is mailed.

Verification



One year (and/or _______ months) of supervised experience in Oregon.



One year (and/or _______ months) of experience as a practicing veterinarian in the

state of _____________.

Applicant received this experience by practicing in (check all that apply):



Private Practice



Residency in a graduate veterinary program* of the following accredited veterinary

school: ______________________________________________.



Preceptorship or externship in a veterinary program* of the following accredited veterinary

school: _____________________________________.

Additional comments:

I, _________________________________________________, certify that I am a licensed

(print name)

veterinarian in the state of _________________, that I have knowledge that the above-named

applicant for an Oregon veterinary license has the experience checked above, and that the statements

herein are true and correct.

(signature)

(date)

(address)

Veterinary License Or Intern License Application - Oregon Veterinary Medical Examining Board Page 5