State Form 44614 - Application For A License To Practice Veterinary Medicine Or Registration To Practice Veterinary Technology Page 2

Download a blank fillable State Form 44614 - Application For A License To Practice Veterinary Medicine Or Registration To Practice Veterinary Technology in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete State Form 44614 - Application For A License To Practice Veterinary Medicine Or Registration To Practice Veterinary Technology with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

TYPE OF LICENSE

STATE

NUMBER

DATE ISSUED

CURRENT STATUS

If your answer is "Yes" to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including location, date

and disposition. Falsification of any of the following is grounds for permanent revocation of a license or registration issued pursuant to this application.

1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held?

Yes

Have you ever been denied a license, certificate, registration or permit to practice veterinary medicine/veterinary technology or any

regulated health occupation in any state (including Indiana) or country?

Yes

3. Are you now, or have you ever been treated for a drug abuse or alcohol problem?

Yes

4. Have you ever been charged with drug addiction?

Yes

5. Have you ever been convicted of, pled guilty or nolo contendre to:

A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled

Yes

substances or drug addiction?

B. To any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines)

Yes

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.

Date (month, day, year)

Signature of applicant

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Health Professions

Bureau of Indiana any files, documents, records or other information pertaining to the undersigned requested by the Bureau, or any of its authorized

representatives in connection with processing my application for a license to practice veterinary medicine or veterinary technology.

I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to

such inspection or furnishing of any such information.

A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION

I hereby swear or affirm, that I have read the above statements and agree to same.

Date (month, day, year)

Signature of applicant

Page 2