Application For Arkansas Veterinary Licensure Page 2
ADVERTISEMENT
1
2
3
4
5
6
7C.
PREVIOUS REGISTRATION(S):
LIST ALL VETERINARY LICENSES CURRENTLY OR PREVIOUSLY HELD, WHETHER TEMPORARY OR
PERMANENT (A Verification of Licensure form must be completed by each state listed and returned to
this Board):
DOES NOT APPLY
STATE
DATE OF ISSUE
EXPIRATION DATE
LICENSE NO
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
______________
______________
_________________
___________
D.
PERSONAL HISTORY INFORMATION:
1.
Have you ever been denied a license to practice veterinary medicine?
NO
YES
2.
Do you currently have any disciplinary investigation(s) and/or action(s)
pending against you in another jurisdiction?
NO
YES
3.
Has any license presently or previously held by you ever been sanctioned,
revoked, suspended, placed on probation and/or otherwise been the
subject of any disciplinary review in another state?
NO
YES
4.
Have you ever been convicted of, plead guilty to, or plead nolo contendre
to a felony or misdemeanor, other than for minor traffic violations?
NO
YES
5.
Have you ever had a registration issued by a controlled substance authority
revoked, suspended, limited or restricted?
NO
YES
6. Have you ever voluntarily surrendered a registration issued by a
controlled substance authority?
NO
YES
7. Have you ever voluntarily surrendered a veterinary license?
NO
YES
If you answered “YES” to any of the above, explain in detail on a separate sheet of
paper and attach it to this application. If you answered “YES” to #5, please submit
official documents with this application.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business