Form Vet-04 1016r - Application For Exam/license - Veterinarian (Page 5 of 7) in pdf

Ef f . Dat e

Lic. No

VETERINARIAN

APPLICATION FOR EXAM/LICENSE –

Access

VE -

this form via website at:

)

(LAST)

LEGAL NAME (First , Middle

Residence Address (include apt . no., cit y, st at e & zip code)

Mailing Address (ONLY if dif f erent f rom above)

Other Names Used (include maiden name):

Indicate type and date of exam. See exam schedule.

[

]

NAVLE exam. Exam Window Applying for

Social Security No.

Phone No. (days)

[

]

Board Licensing exam. Exam Date

ANSWER all the follow ing questions by circling your answ ers. PROVIDE details and explanations w hen needed or required.

Are you at least 18 years of age? ..................................................................................................................................................... YES

Are you a U.S. citizen, a U.S. national, or an alien authorized to w ork in the United States? .................................................................. YES

Did you graduate (or do you expect to graduate w ithin 6 months) from an AVMA-accredited veterinary college? ..................................... YES

Date of Graduation:

4) a. Have you passed the National Board of Veterinary Medical examiners (NBVME) examination? ................................................................ YES

If your answ er is " YES" , w hen did you request scores to be sent directly to the Board? __________________________

Which NBVME examination did you pass?

NAVLE

NBE/CCT

If your answer to 4a is "YES", skip questions 4b. and 4c.

b. Have you taken the NBVME examination, but have not yet received your scores? ................................................................................. YES

If "YES", w here and w hen did you take it?

c. Do you plan to take the NBVME examination in the near future? ......................................................................................................... YES

If "YES", where and when are you planning to take it?

5) a. If you hold an out-of-State veterinarian license, provide the information requested in the table below .

b. Have any licenses granted to you ever been revoked, suspended, or otherw ise subjected to disciplinary action? ...................................... YES

If "YES", you MUST provide an explanation and have the licensing authority of the state of your licensure submit pertinent documents.

c. Are you presently being investigated or are there any disciplinary actions pending against your license? .................................................. YES

If "YES", you MUST provide an explanation and have the licensing authority of the state of your licensure submit pertinent documents.

Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? ...................... ....................................YES

If you answer "YES", you MUST provide an explanation and provide certified court documentation on the date, place, and nature of

each conviction, and the status of fulfillment of conditions of each sentence.

Date "Verification of

Date

License

License – VET-04"

State of Licensure

Issued

Number

Method of Licensure

form mailed to State:

[

] National Licensing Exam

[

] State Licensing Exam

[

] Endorsement

[

] National Licensing Exam

[

] State Licensing Exam

[

] Endorsement

Affidavit of Applicant:

I hereby certify that the statements, answ ers and representations made in this application and the documents attached are true and correct. I

understand that any misrepresentation is grounds for refusal to grant or subsequent revocation of license and is a misdemeanor (Section 710-1017, Sections

436B-19, and 471-10, Haw aii Revised Statutes). I further certify that I have read and w ill abide by the provisions of Chapter 471, Haw aii Revised Statutes,

Chapter 16-101, Haw aii Administrative Rules, and Chapter 436B, Haw aii Revised Statutes.

Date

Signature of Applicant

This material can be made available for individuals w ith special needs. Please

App .............................. 654 ....................... $100

call the Licensing Branch Manager at (808) 586-3000 to submit your request.

Exam ............................ 655 ....................... $30

License ......................... 656 ....................... $130

CRF .............................. 657 ....................... $50/100

½ Renew al .................... 650 ....................... $130

VET-01 1016R

Service Charge .............. BCF ....................... $25