Equine Dentistry Information - Arizona State Veterinary Medical Examining Board

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Arizona State Veterinary Medical Examining Board
9535
E. Doubletree Ranch Road, Suite 100, Scottsdale, AZ 85258
Phone: 602-364-1PET(1738) ♦ Fax: 602-364-1039
vetboard.az.gov
Victoria Whitmore, Executive Director
Douglas A. Ducey
Governor
EQUINE DENTISTRY INFORMATION
Alternative Format for Submitting Application:
An individual with a disability who, as a result of the
disability, requires this registration to be in an alternative format may contact the Board’s Americans with
Disability coordinator at (602) 364-1738, or Voice Relay Service (800) 842-4681 or TTY at (800) 367-8939 to
make their needs known.
Name: ____________________________________________________________________________________
Address: _______________________________________________________________________________________________
Mailing Address (if different): ___________________________________________________________________________
Home Phone: ____________________ Cell phone: ___________________ Fax Number: ___________________
PLEASE COMPLETE ALL OF THE FOLLOWING
1. I am certified by: ______________________________________________ Effective Date: ________________
Continuing Certification Date:______________________________________________________________
Provide proof of current certification from the International Association of Equine Dentistry or the
Academy of Equine Dentistry.
2. Attach a written statement signed by each supervising licensed veterinarian that the certified equine
dental practitioner will be under the general or direct supervision of the licensed veterinarian: A.R.S
.
(B)(3).
§32-2231
3. I will be supervised by the following Arizona licensed veterinarian(s): (If additional space is required,
please attach a separate sheet of paper.)
Veterinarian’s Name: __________________________________________________
Clinic Name: ___________________________________________________________________
Clinic Address: ___________________________________________________________________________
Clinic Phone: _________________________
Veterinarian’s Name: ___________________________________________________
Clinic Name: ________________________________________________________________
Clinic Address: ____________________________________________________________________
Clinic Phone: _______________________
Veterinarian’s Name: ______________________________________________
Clinic Name: _____________________________________________________________
Clinic Address: ___________________________________________________________________
Clinic Phone: _______________________
I hereby declare under penalty of perjury under the laws of the state of Arizona that the answers I
have given are true and correct to the best of my knowledge.
________________________________________________________________/____________________
Signature
Date
Revised 12/15

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