Applying on the Basis of Examination

Transcription

1 Vermont Secretary of State, Board of Veterinary Medicine Montpelier, Vermont PHONE: (802) FAX: (802) address: Web site: VETERINARIAN APPLICATION - INSTRUCTIONS TO APPLICANTS You may apply on the basis of examination or endorsement (See instructions for each method of application below). To qualify for licensure on the basis of examination, your national examination score(s) must be within two years from the date you passed the examination(s). Applying on the Basis of Examination Your application must be complete before it will be sent to the Board for review. All required documents must be received by this Office within six months or this application will be deemed invalid. To qualify for licensure on the basis of examination, your national examination score(s) must be within two years from the date you passed the examination(s). te: Applicants applying on the basis of examination do not need to complete the Continuing Veterinary Medical Education form. 1. Completed information. COMPLETED APPLICATION BY EXAMINATION MUST INCLUDE: 2. Application Fee of $ (Make check payable to Vermont Secretary of State.) Application fees are nonrefundable. 3. Verification of Good Standing form. Complete the top portion of the form and forward it to every state in which you now hold or have ever held a license to practice veterinary medicine. The state/jurisdiction sends the completed form to this Office. 4. Certificate of Veterinary Medical Education. Proof of graduation from an American Veterinary Medical Association (AVMA) accredited program. Complete the top portion of the form and forward it to your school; the school sends the completed form to this Office. Foreign Graduates: Applicants who are not graduates of schools of veterinary medicine accredited by the American Veterinary Medical Association (AVMA) must possess a certificate issued by the Educational Commission for Foreign Veterinary Graduates (ECFVG), its successor organization or an organization acceptable to the Board, or a Certificate of Qualification issued by the Canadian Veterinary Medical Association. Please note: Vermont accepts the American Association of Veterinary State Board s (AAVSB), Program for the Assessment of Veterinary Education Equivalence (PAVE). 5. Proof of successful completion of the rth American Veterinary Licensure Examination (NAVLE). All applicants must request verification directly from the American Association of Veterinary State Boards (AAVSB). Veterinary Information Verifying Agency (VIVA), 3100 Main Street, Suite 208, Kansas City, MO Ph: (877) 698-VIVA info@aavsb.org Web Page: Applying to sit for the NAVLE Examination You may apply directly to the National Board of Veterinary Medical Examiners (NBVME) to sit for the rth American Veterinary Licensure Examination (NAVLE) for Vermont. You must register to sit for the NAVLE directly with the NBVME. Examination fees are paid directly to the NBVME. The NBVME will determine eligibility based on Vermont s requirements. You will not be eligible for licensure in Vermont until you have graduated and met all other requirements. The NBVME will send you a NAVLE Bulletin of Information along with an approval letter. Your scores will be sent to you and to the Vermont Board of Veterinary Medicine.

2 Applying on the Basis of Endorsement Applicants Currently Licensed in Another State or Jurisdiction Your application must be complete before it will be sent to the Board for review. All required documents must be received by this Office within six months, or this application will be deemed invalid. To be eligible for licensure on the basis of Endorsement you must hold a current license in good standing in another United States or Canadian jurisdiction whose licensing standards are substantially equivalent to those of Vermont; and have met the continuing education requirements. 1. Completed application. COMPLETED APPLICATION FOR LICENSURE BY ENDORSEMENT MUST INCLUDE: 2. Application Fee of $ (Make check payable to Vermont Secretary of State.) Application fees are nonrefundable. 3. Verification of Good Standing form. Applicant completes the top portion of the form and forwards it to every state in which you now hold or have ever held a license to practice veterinary medicine. The state/jurisdiction sends the completed form to this Office. 4. Submit evidence of having met Vermont s continuing veterinary medical education requirements. Vermont requires documentation of 24 hours of continuing veterinary medical education from Board-approved state, regional, or national veterinary medical education programs. See Board Rule All applicants must request verification directly from the American Association of Veterinary State Boards (AAVSB). Veterinary Information Verifying Agency (VIVA), 3100 Main Street, Suite 208, Kansas City, MO Ph: (877) 698-VIVA info@aavsb.org Web Page: The AAVSB will verify your examination(s), the rth American Veterinary Licensure Examination (NAVLE), or the National Board Examination (NBE) and the Clinical Competency Test (CCT). 6. Certificate of Veterinary Medical Education. Proof of graduation from an American Veterinary Medical Association (AVMA) accredited program. Complete the top portion of the form and forward it to your school; the school sends the completed form to this Office. 7. Foreign Graduates: (26 V.S.A (c)) Applicants who are not graduates of schools of veterinary medicine accredited by the American Veterinary Medical Association (AVMA) must possess a certificate issued by the Educational Commission for Foreign Veterinary Graduates (ECFVG), its successor organization, or an organization acceptable to the Board, or a Certificate of Qualification issued by the Canadian Veterinary Medical Association. Please note: Vermont accepts the American Association of Veterinary State Board s (AAVSB), Program for the Assessment of Veterinary Education Equivalence (PAVE). YOU CANNOT BEGIN TO WORK IN VERMONT UNTIL YOU HOLD A LICENSE. NOTE: All licensees renew on a fixed 24 month schedule: May 31 (odd numbered years). Applicants issued an initial license more than 90 days prior to the renewal date will be required to renew and pay the renewal fee. Initial licenses issued within 90 days of the renewal date will not be required to renew and pay the renewal fee.

3 Vermont Secretary of State Montpelier VT (802) Vermont Board of Veterinary Medicine Licensing Board Specialist Aprille Morrison (802) Applying on the basis of: Examination or Endorsement (Licensed in another state/jurisdiction) First Name (Legal name; no nicknames) MI Last Name Previous Name(s) (Maiden) Social Security Number: ** (Providing your social security number (SSN) is mandatory, and requested under the authority granted by 42 U.S.C. 405(c)(2)(C). It will be used by the Departments of Taxes, Child Support, and the Department of Labor in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request); OR Passport Number: *** (If you do not have a social security number you must provide a passport number as evidence that there is no attempt to procure a license fraudulently (3 V.S.A. 129a) P.O. Box Mailing Address: Street/Apt # City/State/Zip Country 911 or Physical Address: (if different than mailing) Box Street/Apt # Suite/Department/Floor City/State/Zip Phone: Fax: Cell Phone: Date of Birth (MM/DD/YYYY) Gender: (Circle One) DEA # / / Male Female List below every state in which you now hold, or have ever held, a license/certification to practice STATE LICENSE # DATE ISSUED DATE EXPIRES(D)

4 Vermont Mandatory Good Standing Declarations Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.

5 Vermont Mandatory Credential and Fitness Questions Circle or for each of these questions. If the answer is, follow the instructions provided. Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Have you ever surrendered a license, certificate or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Have you EVER been convicted of a crime other than a minor traffic violation? (Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. ) If, you must provide a detailed written explanation and attach the official court documents (i.e., affidavit of probable cause, the information and/or the docket report.) Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. te: Vermont law requires that you report to the a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation.

6 Profession Specific: Veterinary Education: Name and location of College or University Attended Degree Received Date Graduated Place of Employment: City State Zip Phone Fax Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Date Mail Completed Application to: Vermont Secretary of State Board of Veterinary Medicine Montpelier, VT

7 Vermont Secretary of State BOARD OF VETERINARY MEDICINE Montpelier, VT Certificate of Veterinary Medical Education APPLICANT: Complete the top of this page and forward it to your Veterinary college/school. Applicant's Name: (Last) (First) (MI) (Former) Address: Date of Birth: Social Security # / / Name of Institution: Date of Graduation: Degree(s): Applicant's Signature: Date: TO BE COMPLETED BY THE INSTITUTION GRANTING DEGREE(S): Please complete and return this form directly to the address listed above: Applicant's Name: Name of Veterinary College: Address of College: Date of Admission: Date completed all requirements for graduation: Date Doctorate of Veterinary Medicine was granted: Was this College of Veterinary Medicine accredited by the American Veterinary Medical Association at the time of this student's graduation? Signed Title Date (Authorized agent of the institution) (SEAL)

8 Send completed CVME form with your Endorsement application and fee to: Vermont Board of Veterinary Medicine Montpelier, VT CONTINUING VETERINARY MEDICAL EDUCATION YOUR NAME: LICENSE NO.: Applicants applying on the basis of endorsement (licensed in another jurisdiction) must complete this form to document their continuing veterinary medical education. The Board reserves the right to verify information submitted by applicants. Itemize the continuing veterinary medical education courses you have taken in the two years immediately preceding your application to Vermont. Attach additional pages if necessary. For Vermont s requirements see Board Rule 3.7, Course Name Sponsor Location Date # of Hours Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for licensure/certification/registration. (The maximum penalty for perjury is Fifteen years in prison and/or a $10,000 fine.) (13 V.S.A. 2901) Signature of Applicant Date

9 Vermont Secretary of State Montpelier VT Verification of Licensure (802) VERIFICATION OF LICENSURE Complete the applicant section of this form and have every state in which you now hold or have ever held a license/certification to practice complete this page. Licensed as a: Date of Birth: Applicant: First Name MI Last Name & Title (Jr., Sr., II, III, etc.) Former/Maiden P.O. Box Mailing Address: Street/Apt # City/State/Zip Country I hereby authorize the License Agency to furnish to the Vermont the information requested below. Signature Date: Information Below To Be Completed by the Licensing Agency: License # Date Issued: Date Expired: License as a: Licensed By: Examination/Education Endorsement/Reciprocity Waiver License Status Has this license ever been encumbered in anyway (revoked, suspended, limited, surrendered, restricted, placed on probation)? If yes, attach a copy of the decision Active Inactive Lapsed YES NO Signature of person completing form: Date: State Completing this form: City/State: Telephone: STATE LICENSING AUTHORITY: Mail to Vermont Secretary of State Montpelier, VT (OFFICIAL SEAL)