Attestation Of Veterinarian'S Provision Of Free Spaying And/or Neutering Services For Continuing Education Credit Page 2
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1
2Use the following log to record each instance where you provided free spaying and/or neutering services for the purpose of
satisfying a portion of your continuing education requirement (use additional sheets if necessary).
1.
Location where service took place _______________________________________________________________________________
Address: ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date of service: ___________________________________________________________ Number of Hours claimed: ____________
2.
Location where service took place _______________________________________________________________________________
Address: ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date of service: ___________________________________________________________ Number of Hours claimed: ____________
3.
Location where service took place _______________________________________________________________________________
Address: ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date of service: ___________________________________________________________ Number of Hours claimed: ____________
4.
Location where service took place _______________________________________________________________________________
Address: ___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date of service: ___________________________________________________________ Number of Hours claimed: ____________
Attestation
I hereby attest that I am in compliance with all the mandatory continuing education requirements for veterinarians in section 6704-a of the
Education Law and section 62.8 of the Regulations of the Commissioner of Education. I further attest that the statements and information
contained herein and in any documents attached hereto, are, to the best of my knowledge true and accurate. I also acknowledge that any
false statements and/or information may, among other things, subject me to the full disciplinary and regulatory authority of the Board of
Regents and the Department pursuant to Title VII of the Education Law.
Signature: ___________________________________________________________________ Date: _____________________________
Print Name: __________________________________________________________________
Veterinarian - COS Form, Page 2 of 2, February 2017
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