State Form 44614 - Application For A License To Practice Veterinary Medicine Or Registration To Practice Veterinary Technology

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APPLICATION FOR A LICENSE TO PRACTICE
Health Professions Bureau
VETERINARY MEDICINE OR REGISTRATION TO
402 W. Washington St., Rm. 041
PRACTICE VETERINARY TECHNOLOGY
Indianapolis, IN 46204
(Application For Licensure/Registration)
State Form 44614 (R4 / 4-96)
Approved by State Board of Accounts 1991
Your Social Social Security Number is being requested by this state agency in accordance with I. C.
4-1-8-1. D isclosure is mandat ory, and t his record cannot be processed without.
OFFICE USE ONLY
License / Registration issuance date
Exam / End / Issue fee
Receipt number
License / Registration number
Applicant
350-01/02/09
Attach two (2) passport type
Date fee paid (month, day, year)
quality photographs of yourself
taken within the last year.
Please sign each photo at the
APPLICANT INFORMATION
bottom. Negative and Polaroids are
Name of applicant (last, first, middle, maiden)
* Social Security number
not acceptable.
Address (number and street or Rural Route number)
City, state, ZIP code
Telephone number (daytime)
Birthdate (Month, day, year)
Birthplace
TYPE OF LICENSE/REGISTRATION
Applying as a (check appropriate box)
Examinations: (check box)
Veterinarian
CCT
Veterinary Technician National Examination
Endorsement
Veterinary Technician
NBE
DEGREE GRANTED BY
Name of school
Location of school
Date of graduation (month, day, year)
PROFESSIONAL EDUCATION IN VETERINARY MEDICINE/TECHNOLOGY
NAME OF SCHOOL
LOCATION OF SCHOOL
DATES ATTENDED
EXAMINATION RECORD
National Board Exam
If Yes, how many times?
Date of most recent test (month, day, year)
Where taken (state or country)
Yes
No
Clinical Competency Test
If Yes, how many times?
Date of most recent test (month, day, year)
Where taken (state or country)
Yes
No
If Yes, how many times?
Veterinary Technician National Exam
Date of most recent test (month, day, year)
Where taken (state or country)
Yes
No
Do you hold, or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation?
Yes
No
Have you been engaged in active practice for the five (5) years immediately filing this application?
Yes
No

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