WEST VIRGINIA BOARD OF VETERINARY MEDICINE
VETERINARIAN APPLICATION FOR EXAMINATION AND LICENSE
You must answer completely and precisely all questions. Misstatements, fraudulent, or insufficient answers and data required will be reason for rejection of your application. All answers must be sworn by you, before a notary public. Use additional paper as necessary.
You must be a graduate veterinarian or graduating within 90 days or less from our exam date in order to apply.
1 . Full Name ______________________________________________ Age ___________
First Middle Last
2 . Permanent mailing address _________________________________________________
Street City State Zip code
3 . Telephone number _________________________________ Area Code _____________
4 . Birth date ________ Place of birth ___________________________________________
5 . Attach a photostatic copy of your birth certificate
6 . If birth name differs from current name, submit proof of name change, such as a copy of marriage license.
7 . Citizen of USA ______ Applied for US citizenship ______ Work Permit __________
8 . If foreign born, give date and place of immigration to this country, and date and place of naturalization ______________________________________________________________
9 . Attach proof of naturalization or authority to reside and work in the United States
10 . Social Security No. _____________________________
11 . Attach or have school send to us a certified copy of your transcripts of records from the schools or colleges of veterinary medicine attended, which shows total number of hours attended, subjects studied, grades given and date of graduation.
12 . School of graduation _________________________________________
13 . School location _____________________________________________
14 . Date of graduation __________________________________________
15. If a diploma is not yet presented to you, you must submit to this board a notarized copy with notary seal upon receipt of the diploma, along with a statement from the notary public verifying that the copy submitted is an exact copy of the original document.
16. If your school is not accredited by the AVMA, or if you are a graduate of a foreign veterinary school, attach proof of meeting the requirements of the Educational Commission for Foreign Veterinary Graduates, advisory to the council of the AVMA on education.
17 17. Your National Board Exam and Clinical Competency Exam scores or your NAVLE scores must be submitted to the Board directly from VIVA. Indicate which tests you have taken:
NBE ________ CCT ________ NAVLE ________
17a. If you checked the NAVLE , and West Virginia was the state that determined your eligibility for the NAVLE exam, check here ___________.
( If approved for NAVLE through WV, we have your NAVLE scores on file, so you do not need them submitted from the reporting service)
18. 18. Have you ever been convicted of a criminal offense? ______
19. 19. Has your veterinary license ever been surrendered, suspended, dismissed or revoked ? ____ Have you ever been refused the right to be examined, or refused a license to practice veterinary medicine? ____ Has your Federal DEA number ever been surrendered, suspended or revoked? _____ If YES to any of the foregoing, you must give complete details supported by official records.
20. Have you served in the Armed Forces of the USA or any other country? ____ If YES, which country _________ branch __________________ serial no. ____________________
21. If your discharge from the Armed Forces was other than honorable, attach details supported by official documents.
22. Are you now, or have you ever been licensed in any state or jurisdiction? ____ If YES, list all such states/jurisdictions ______________________________________________________
23. You must have all states/jurisdictions where you now hold or have ever held a veterinary license submit under seal directly to the West Virginia Board of Veterinary Medicine confirmation of your standing while licensed, and your current status.
24. Please attach a Post Office money order or a cashiers check for $325.00 covering application, examination, license fee and a copy of the practice act and rules and regulations, (which is your test material). Check is payable to the West Virginia Board of Veterinary Medicine. If applying for a temporary permit, add an additional $100.00, making total remittance $425.00. Indicate Amt. Being Submitted: $____________
25. Pursuant to WV Code §48-15-303, each applicant for license must answer the following questions and certify, under penalty of false swearing, that these answers are true and correct.
25.1. Do you have a child support or medical support obligation? ___ YES ___ NO
25.2. If the answer to 25.1. is YES, are you in arrears? ___ YES ___ NO
25.3. If the answer to 25.2. is YES, do your arrears equal or exceed the amount of child support or medical support payable for six (6) months? ___ YES ___ NO
25.4. Are you the subject of a child support or paternity related subpoena or warrant? __ YES ___ NO
If you make a false statement concerning any question on this application, you may be subject to disciplinary action including, but not limited to, revocation or suspension of your license.
I, ___________________________ do hereby certify, under penalties of perjury and false swearing, that I have personally completed this application and the above answers are true and correct to the best of my knowledge. _______________________________
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 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, and that if a license is issued in my favor, I will respectfully comply with the laws of West Virginia regarding the practice of veterinary medicine in this state.
The above statement was sworn to and subscribed before me by the applicant this __________ day of _____________, A.D., two thousand and _______ .
Notary Public ______________________________
Do Not Write Below This Point
This application and appropriate fee must be received by the WV Board of Veterinary Medicine no later than Dec. 12, 2008
Return this completed application with payment to:
West Virginia Board of Veterinary Medicine
Ms. Wanda Goodwin: Executive Director
5509 Big Tyler Road, Suite 3
Cross Lanes WV 25313
Phone: (304) 776-8032; Fax: (304) 776-8256;
Examination will be given
Date: January 12, 2009
Time: 8:00 a.m.
Place: (exact location TBA)