West Virginia Board of Veterinary Medicine
      Certified Animal Euthanasia Technician (CAET) Application
                       You must answer completely and precisely all questions .
           Misstatements,   fraudulent or insufficient answers and data will be reason for rejection of your application.  
          All answers must be in legible handwriting, and  sworn by you, before a notary public. Use additional paper as necessary.

  If you make a false statement concerning any question on this application, you may be subject to  disciplinary action  including, but   not limited to, immediate revocation or suspension of your certification.
                                                           First                           Middle                        Last
 1.Name: _____________________________________________________________________

2.Permanent Mailing Address: ____________________________________________________

3. Telephone number: __________________________________ Area Code: _______________

4. Birth Date: __________________ Place of Birth: ___________________________________

5. Social Security #: ____________________________________________________________

6. Attach a Photostatic copy of your birth certificate.

7. If current name differs from birth name, attach documentation of any and all name changes 
  (such as marriage  certificate).

 8.   Attach a recent photograph of yourself, approximately 2 by 2 inches in size, with your signature  on  the back  in indelible ink. No photocopies or scanned photos allowed. Only you shall be in the  photo.   

  9. Check One: Citizen of USA: _____ Have applied for US citizenship _______ Green Card: _____

10. If foreign born, give date and place of immigration to this country, and date and place of naturalization, if applicable: _____________________________________

11. If not a US citizen, you must submit proof of authorization to work in the U.S.

12. Have you ever been involved in any civil or criminal proceedings as a party or witness? _____ If Yes, Explain:____________________________________________________________  
       
 13.Have you ever been convicted of a criminal offense? ____If Yes, Explain: ___________________________________________________________________________

14. Name of the humane society or animal control facility where you will work as a Certified Animal Euthanasia Technician: ________________________________________________________

15. Physical address of the humane society or animal control facility where you will work as a Certified Animal Euthanasia Technician: ____________________________________________

16. Director or manager of the humane society or animal control facility listed above: _____________

17. Attach a letter of recommendation bearing date and original signature from the director or manager of the animal control facility, approving and authorizing your application for certification as animal euthanasia technician for that specified facility. If you are director, the letter shall be from county official or supervisor.

18. Phone number of the humane society or animal control facility listed above: _______________

19. Is this facility a legally (501c) authorized humane society or animal control facility? __________

20. Submit verification of facilities authority to operate as a humane society or animal control facility, such as a certificate of 501c(3) status by the Internal Revenue Service, or letter from county commission bearing an original signature of submitter, stating facility is an entity of county government

21. Attach a money order or check in the amount of $305.00, payable to the West Virginia Board of Veterinary Medicine. These monies are for the training program, application/examination, veterinary practice act and rules & regulations, and background check by WV State Police. Fees or any portion thereof is non-refundable.

22. You must attach a letter from you, authorizing the West Virginia Board of Veterinary Medicine to make inquiries through the United States Department of Justice or any other legal jurisdiction or entity for purposes of determining your character and reputation, as well as other matters relating to your certification.

Pursuant to WV Code 48-15-303, each applicant for certification must answer the following questions and certify, under penalty of false swearing, that these answers are true and correct.

 23. Do you have a child support or medical support obligation? Yes ____ No ____
24 . If the answer to number 23. is YES, are you in arrears? Yes ____ No ____
25. If the answer to number 24. is YES, does your arrearage equal or exceed the amount of child support or medical support payable for six (6) months? Yes ____ No  ____
26. Are you the subject of a child support or paternity related subpoena or warrant? Yes ____No ____

                  Print Name
 I, ________________________________, do hereby certify under penalties of perjury and false swearing, that the above questions are answered truthfully and correctly to the best of my knowledge. I understand that making a false statement may subject my license, if administered, to disciplinary action including, but not limited to, immediate revocation or suspension of the license.
 __________________________________Applicant's Signature
            

           Print Applicants Full Name
 I, _________________________, being of full age and being duly sworn according to law, state that I am the person referred to in the foregoing statement, that I have carefully read the instructions given and the questions asked in the application form, and that all statements made therein are true and correct. I further depose and state that I am of good moral character, never having been convicted of a felony or misdemeanor involving moral turpitude. If a certification as an animal euthanasia technician is issued in my favor, I will respectfully comply with the laws and rules governing certification as an animal euthanasia technician in the state of West Virginia, and will do my best to uphold and maintain the ethical standards of this profession.


Sworn to and subscribed before me, this _______ day of _______________, A.D., Two Thousand and _____ .             Notary Public Signature      ______________________
Applicant s Signature   __________________________ 

                                                       

 

                                                                                            AFFIX NOTARY STAMP/SEAL



 

You must submit all pages of this application form.

Do Not Write Below This Line
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This application must be received by the WV Board of Veterinary Medicine by: April 16, 2008

Training Program will be given: 

Date: May 16 & May 17, 2008     
Time: 8:00AM
Place: Fairmont State University, Fairmont, WV

Examination will be given:
Date: May 18, 2008     
Time: 9:00 AM          
Place: Fairmont State U.