Application For Arkansas Veterinary Licensure
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7APPLICATION FOR ARKANSAS VETERINARY LICENSURE
INSTRUCTIONS:
Applications must be received no later than 30 days prior to the Written State Board
Examination (NAVLE applicants – applications must be received no later than August 1
for the November-December NAVLE and February 1 for the April NAVLE).
Type or print legibly with black or blue ink only.
The application fee ($100.00) must accompany this form and is nonrefundable.
Complete each section fully. If a question does not apply to you, indicate with “N/A”.
DO NOT LEAVE ANY BLANKS.
Use a separate sheet of paper to respond to any question for which more space is
needed.
APPLICANT STATUS:
Fourth Year Student or New Graduate
Licensed practicing less than 5 years
Student or Graduate of Foreign
Licensed practicing more than 5 years
Veterinary School
I am applying for licensure by:
EXAMINATION
POULTRY SPECIALTY
ENDORSEMENT
A. APPLICANT IDENTIFYING INFORMATION:
FULL LEGAL NAME:
(
)
Last
First
Middle
Maiden
MAILING ADDRESS:
Street/P.O. Box
City
State
Zip
BUSINESS ADDRESS:
_________________________________________________________________________________________
Street/P.O. Box
City
State
Zip
PHONE: (______) ____________________________
BUSINESS PHONE: (______) ________________________
FAX:
(_____)_____________________________
EMAIL ADDRESS: ________ ________________________
DATE OF BIRTH: ______/_______/______ AGE: ____
SOCIAL SECURITY NUMBER: _________-_______-_________
(Required Under Ark. Code Ann. §17-1-104)
PLACE OF BIRTH: ____________________________________
MALE: ______ FEMALE: ______ RACE: __________________
B. EDUCATION:
PRE-VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREES EARNED
VETERINARY
NAME OF SCHOOL
LOCATION
DATES ATTENDED
DEGREES EARNED
SUBMIT COPY OF DIPLOMA FROM VETERINARY COLLEGE
(8-1/2 x 11” copy preferred)
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