West Virginia Board of Veterinary Medicine

                                          Veterinary Facility Annual Registration
                          Fiscal Year 2009 (July 1, 2008-June 30, 2009)

All veterinary facilities in West Virginia must be registered with the West Virginia Board of Veterinary Medicine, and must submit annual registration and dues for such premise.
Fee for each veterinary facility is $50.00, ($62.50, if received by the Board after June 30, 2008 payable to the West Virginia Board of Veterinary Medicine. New facilities pay current amount unless filing after opening date of facility.
 This facility permit is for the fiscal year period of July 1, 2008 through June 30, 2009 If facility is not in compliance with the requirement that facility be registered, veterinary license renewal will be denied to veterinarian(s) in charge or veterinarian shareholders, if incorporated

 Type or print legibly. All questions on pages 1 and 2 must be answered or registration will not be processed.
1. Facility Name: _________________________________________________________
2. If facility closed, date of closure: ____________________________________________
3. West Virginia County in which this veterinary facility is located: _____________________
4. Type of veterinary facility (check one):
Veterinary Care Facility __   Mobile Facility ___
Emergency Facility ___    Secondary Outpatient Facility ___
5. Physical address of veterinary facility:________________________________________________________________
6. Mailing address of veterinary facility: _______________________________________________________________________
7. Owner(s) or operator(s) of this veterinary facility ________________________________
8. Phone number of this veterinary facility : ______________________________________
9. Hours of operation of this veterinary facility: ___________________________________
10. Approximate date of establishment of this veterinary facility: _______________________
11. Is the veterinarian operating this facility the facility owner? ________________________
12. Is this veterinary facility incorporated? _______________________________________
13.  If the answer to 12 is YES, is corporation current on veterinary corporation dues payable to the West Virginia Board of Veterinary Medicine, with annual corporation certificate on file in your veterinary facility? ____________________________________________________
14. Primary operation of this facility (select one)
Sm. animal ___  Lg. animal ___(Specialty species, if applicable, e.g., equine, bovine) ______
Mixed ___ Other ___ If other, specify research, teaching institution, gov't, etc.____________
15. Number of veterinarians at this veterinary facility, either full or part time.______________
16. Name(s) of veterinarians employed at this facility: (use separate page, if necessary) _________________________________________________________________________________________________________________________________________________________________________________________________________________
17. Does facility employ any Registered Veterinary Technicians, either full or part time? _____
18. Name(s) of RVT's employed at this facility: ________________________________________________________________________________
19. Enclose a check or money order payable to the West Virginia Board of Veterinary Medicine, in the amount of $50.00, if received by the Board no later than June 30, 2008. If received by the Board after June 30, 2008, amount due is $62.50 (unless this is a new facility establishing after June 30, 2008 and registration is filed in the Board office prior to its beginning operation).
20. Are there other veterinary facilities in WV under the same ownership? _______________
21. If YES to 20, specify other facilities name(s) and  address(es).______________________________________________________________________________________________________________________________
I swear by my signature below that all questions on this Veterinary Facility Annual Registration form have been answered completely and honestly
22. Signature of veterinarian in charge. ____________________________ Date: ________
23. Print name of signature authority listed on line 22. ______________________________
(Do not write below this line)
Return Completed Form and Payment To:
WV Board of Veterinary Medicine
5509 Big Tyler Road, Suite #3, Cross Lanes, WV 25313

Posted by Board _________