Application For Kansas Veterinary License Page 3
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1013.
From all states in which you are now or ever have been licensed, you must submit LETTERS OF
GOOD STANDING. This verification should be sent directly from the state(s) responding to the
Kansas board. Our mailing address is:
Kansas Board of Veterinary Examiners
PO Box 379
Wamego, Kansas 66547-0379
14.
The following information is required by the Kansas Board for licensure and is true and
complete under penalty of law. You must enclose on a separate sheet a complete explanation
for any YES answer below.
CIRCLE ONE
YES
NO
1.
Are you currently enrolled in an ECFVG program or the holder of an ECFVG
certificate?
YES
NO
2.
Are you registered or licensed in any other profession?
YES
NO
3.
Have you ever been denied licensure to practice veterinary medicine in any
state, US territory, or country for any reason other than examination failure?
YES
NO
4.
Has your license to practice veterinary medicine from any state ever been
subject to any disciplinary action or are any such actions now pending?
YES
NO
5.
Have you ever been convicted of any felony or misdemeanor? (exclude minor
or juvenile offenses)
YES
NO
6.
Have you ever been convicted of a charge of cruelty to animals?
YES
NO
7.
Have you received treatment for substance abuse in the last five years?
YES
NO
8.
Has the Federal Drug Enforcement Administration ever taken action against,
withdrawn or warned you on anything pertaining to your DEA Number?
YES
NO
9.
Has there ever been any action taken against or warnings issued to any USDA
Accreditation held by you?
YES
NO
10.
Have you ever been a defendant or a respondent in any malpractice action?
YES
NO
11.
Have you ever voluntarily relinquished or intentionally allowed to lapse any
license, accreditation, DEA number or other certificate necessary for the
practice of veterinary medicine in order to avoid action against such
certificate?
YES
NO
12.
Have you ever attended any other college of veterinary medicine than the
school from which you are a graduate?
YES
NO
13.
Are you now or have you been registered or licensed with any state racing
commission?
YES
NO
14.
Are you a diplomat of any specialty in veterinary medicine?
YES
NO
15.
Are you now using a different name than the name used on any educational
and/or professional documents in your past?
T
B
E
.
HIS APPLICATION SHALL EXPIRE ONE YEAR AFTER IT IS RECEIVED IN THE OFFICE OF THE
OARD OF
XAMINERS
APPLICATION FEE OF $125 IS NOT REFUNDABLE
_________________________________________________________________________________
Make check payable to:
KANSAS BOARD OF VETERINARY EXAMINERS
PO Box 379
Wamego, Kansas 66547
Phone: 785-456-8781
v071814
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