Free 44614.FH11 - Indiana

APPLICATION FOR A LICENSE TO PRACTICE VETERINARY MEDICINE
State Form 44614 (R6 / 2-06) Approved by State Board of Accounts, 2006

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INSTRUCTIONS: Please type or print and answer all questions.

INDIANA BOARD OF VETERINARY MEDICAL EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

* Your Social Security number is being requested by this state agency in accordance with I. C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER LICENSE ISSUE DATE (month, day, year) LAW EXAMINATION DATE (month, day, year) LAW EXAMINATION SCORE

APPLICANT

One (1) passport-quality photograph taken not earlier than eight (8) weeks prior to the date of application, dated and signed across the back in the applicants I certify that this is a true photograph of myself.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route number) City Date of birth (month, day, year) T elephone number State Place of birth (city and state or country) E-mail address ZIP code * Social Security number

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BASIS OF LICENSURE (Please check one) ENDORSEMENT OF EXAMINATION SCORES ENDORSEMENT OF EXAMINATION SCORES ENDORSEMENT (Has not taken and passed NBE, CCT or NAVLE, but has taken and passed a state constructed examination.) Based upon passing the North American Veterinary Licensing Examination (NAVLE) Based upon passing the National Board Examination (NBE) and Clinical Competency Test (CCT) For the five (5) years immediately preceding filing an application has been a practicing veterinarian licensed in a state, territory, or district of the United States having license requirements which are substantially equivalent.

VETERINARY DEGREE GRANTED BY
Name of school Location of school Date of graduation (month, day, year)

EXAMINATION RECORD EXAMINATION TAKEN National Board Examination (NBE) Clinical Competency T (CCT) est North American Veterinary Licensing Examination (NAVLE) State Constructed Examination Have you sat for the NBE, CCT or the NAVLE Examination in Indiana prior to this application? If you are a graduate of a foreign college of veterinary medicine have you completed and been granted certification by the Educational Commission for Foreign Veterinary Graduates (ECFVG)? Page 1 Yes Yes No No DATE OF MOST RECENT EXAMINATION (month, day, year) WHERE TAKEN HOW MANY TIMES HAVE YOU SAT FOR THIS EXAMINATION?

PRE-PROFESSIONAL EDUCATION IN VETERINARY MEDICINE NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED DEGREE GRANTED

TYPE OF LICENSE

STATE

STATES LICENSED NUMBER DATE ISSUED

EXPIRATION DATE

STATUS

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM VETERINARY SCHOOL GENERAL LOCATION

DATES

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM VETERINARY SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITES DATES OF EMPLOYMENT

If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice veterinary medicine or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been treated for drug or alcohol abuse? 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 substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 6. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes Yes No No No No

Yes Yes Yes

No No No

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APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for a license to practice veterinary medicine. 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.
Signature of applicant Date (month, day, year)

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VERIFICATION OF VETERINARY LICENSURE
INSTRUCTIONS: Type or print the top portion of the verification and send a copy to each state where you hold or have held a license. Request each state to complete and send directly to: Indiana Board of Veterinary Medical Examiners Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 (317) 234-2054 E-mail: [email protected]
Name (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) State E-mail address ZIP code Social Security number *

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I hereby authorize the State of
Signature

to furnish to the Professional Licensing Agency with the information below.
Date (month, day, year)

TO BE COMPLETED BY THE STATE BOARD
License number License issued based upon: Date of issuance (month, day, year) Expiration date (month, day, year)

Examination
Type of examination:

Endorsement

Other
Date of examination(s) (month, day, year)

National Board Examination (NBE) Clinical Competency Test (CCT) North American Veterinary Licensing Examination (NAVLE) State Constructed Examination (Attach subjects, scores and average) Has the license been subject to any disciplinary action? (Please attach certified copies of any disciplinary action taken by your board.) FORM COMPLETED BY:
Name Title State Board Date (month, day, year)

Yes

No

PLEASE AFFIX BOARD SEAL

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