Form Vet-04 1016r - Application For Exam/license - Veterinarian Page 6
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7VETERINARIAN
VERIFICATION OF LICENSE
-
State of Hawaii
Access this form via website at:
Board of Veterinary Examiners
P.O. Box 3469
Honolulu, HI 96801
Name (First, Middle)
(LAST)
Social Security No.
Address (Include Apt. No. and Zip Code)
LICENSE NUMBER
VE -
DATE ISSUED
I hereby authorize the licensing agency of the state of
to furnish the
information below to the State of Hawaii Board of Veterinary Examiners.
Date
SIGN HERE
This is to certify that the above-named individual was issued license number
to practice
veterinary medicine on the basis of:
[
] NBVME developed exams
Date issued:
(NAVLE or NBE and CCT)
Date license
[
] Endorsement
expires:
[
] State-constructed exam
License
[
] Reciprocity
status
[
] current
[
] lapsed since:
[
] inactive since:
Has this license ever been encumbered in any way (revoked,
suspended, surrendered, limited, placed on probation,
currently pending disciplinary action, being investigated? ...............
[
] NO
[
] YES (Please explain yes response and attach copy
of board's order and related information.)
COMMENTS:
Signature:
Title:
BOARD SEAL
State:
Date:
TO THE BOARD: Return this form directly to the Hawaii Board of Veterinary Examiners at the address shown at the top of the page
.
(This form may be duplicated)
VET-04 1016R
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