STANDARD VERIFICATION FORM

                               FOR USE BY APPLICANT, SIGNED BY STATE LICENSING BOARD

(Such a form must be completed and returned to West Virginia from each veterinary licensing board where you now hold or have ever held a license to practice veterinary medicine. You may make copies for distribution to those various jurisdictions)

*CHECK WITH THE STATE WHICH YOU ARE ASKING TO SUBMIT THIS VERIFICATION TO DETERMINE IF THERE IS A FEE FOR THIS SERVICE, TO AVOID DELAYS IN PROCESSING.

APPLICANT AUTHORIZATION

NAME: ____________________________ LICENSE #: _________________
ADDRESS: _______________________________________________________
                                         STREET                               CITY                      STATE                   ZIPCODE

I authorize the Veterinary Board of ______________ to release the information below to the Veterinary Medical Board of West Virginia
Applicant Signature and Date: ________________________________________        _________________

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BOARD VERIFICATION

 BOARD NAME _____________________________________________________________

BOARD ADDRESS __________________________________________________________

BOARD PHONE ___________ BOARD FAX ____________ E-MAIL _______________

APPLICANT LICENSE NUMBER ________________

DATE ISSUED __________________

Qualifications for license in year of issue (i.e., exams, experience, etc.): ____________________________________________________________________________

Current license status (i.e., active, inactive, lapsed, etc.): ____________________________

Disciplinary Action? ____NO ______YES
Current Disciplinary Action? ____NO ______YES
Pending Disciplinary Action? ____NO ______YES

If yes to any disciplinary action, please attach a certified copy of the Findings of Fact, Conclusions of Law, and Final Order, or the charges of a pending case.

Signature of Board Official_______________________________ Date _____________

Title ___________________                               Official Board Seal

Submit to: WV Board of Veterinary Medicine, 5509 Big Tyler Road, Suite 3, Cross Lanes, WV 25313