BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
Veterinary Medical Board
1747 N. Market Boulevard, Suite 230, Sacramento, CA 95834 Telephone: 916-515-5220 Fax: 916-928-6849 | www.vmb.ca.gov
VETERINARY APPLICATION
1.APPLICATION TYPE/FEES - check fees you are paying
|
$125.00 - Application Evaluation Fee |
|
|
|
|
|
|
|
|
|
Office Use Only |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Application Fee is Required for all Applications |
|
|
|
|
|
Receipt |
|
|
_______________________________ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
$200.00 - State Board Examination Fee |
|
|
|
|
Number: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date |
|
|
_______________________________ |
|
|
$100.00 - California Veterinary Law Examination Fee, if |
|
|
Cashiered: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
applicable |
|
|
|
|
|
|
|
|
|
|
ATS ID: |
|
|
_______________________________ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Please make check or money order payable to the “VMB” |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Amount |
|
|
_______________________________ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Mail application, supporting documents, and fee to: |
|
|
|
|
|
|
|
|
|
Paid: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Veterinary Medical Board |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
_______________________________ |
|
|
1747 N. Market Blvd., Suite 230 |
|
|
|
|
|
Refund: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sacramento, CA 95834 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2. APPLICANT INFORMATION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LAST |
FIRST |
|
|
|
|
MIDDLE |
|
|
|
|
BIRTHDATE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CURRENT MAILING ADDRESS |
|
|
|
CITY |
|
|
STATE |
|
|
ZIP |
|
|
|
|
COUNTRY |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PERMANENT MAILING ADDRESS |
|
|
|
CITY |
|
|
STATE |
|
|
ZIP |
|
|
|
|
COUNTRY |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
U.S. SOCIAL SECURITY NUMBER*: |
|
|
|
|
|
|
|
TELEPHONE NUMBER: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
EMAIL ADDRESS: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
*Disclosure of a social security number is mandatory and must be provided prior to licensure This number must be a United States social security number. Social security |
|
numbers from other countries will not be accepted. Section 30 of the Business and Profession Code and Public Law 94-455 [42 USC 405(c)(2)(C)] authorize collection of the |
|
Social Security number. Your Social Security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or support order |
|
in accordance with Section 17520 of the Family Code. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3. PHYSICAL DESCRIPTION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HAIR COLOR |
|
HEIGHT |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
EYE COLOR |
|
WEIGHT |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
ATTACH PASSPORT |
I HEREBY DECLARE THAT THE ATTACHED PHOTO |
|
|
|
|
|
|
|
|
|
|
|
SIZE PHOTO HERE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
WAS TAKEN ON OR ABOUT (MONTH/DAY/YEAR): |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CANDIDATE SIGNATURE ___________________________________________________________________ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
4. EDUCATION INFORMATION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COLLEGE OR UNIVERSITY |
|
|
|
FROM |
|
TO |
|
|
COURSE |
|
|
GRADUATION DATE |
DEGREE RECEIVED |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5. STATES/PROVINCES IN WHICH YOU ARE LICENSED AS A VETERINARIAN
STATE/PROVINCE |
REGISTRATION # |
|
|
ISSUED BY EXAM OR CREDENTIALS
6. PREVIOUS APPLICATION(S) FOR CALIFORNIA
HAVE YOU EVER APPLIED TO TAKE THE VETERINARY EXAMINATION IN CALIFORNIA?
7. DISCLOSURE OF DISCIPLINARY ACTION
HAVE YOU EVER HAD DISCIPLINARY PROCEEDINGS AGAINST ANY LICENSE TO PRACTICE VETERINARY MEDICINE INCLUDING REVOCATION, SUSPENSION, PROBATION, VOLUNTARY SURRENDER, OR ANY OTHER PROCEEDING?
If Yes, please provide detailed written explanation, include the date and state where the discipline occurred.
8. CONVICTION OF MISDEMEANOR OR FELONY
HAVE YOU EVER BEEN CONVICTED OF ANY OFFENSE OTHER THAN MINOR TRAFFIC VIOLATIONS OR PLED NO CONTEST TO A VIOLATION OF ANY LAW OF ANY STATE, THE UNITED STATES, OR A FOREIGN COUNTRY?
If Yes, please provide detailed written explanation.*
*You must include all misdemeanor and felony convictions, regardless of the age of the conviction, including those which have been set aside and/or dismissed under Penal Code Section 1000, 1203.4 or 1210.1. Traffic violations involving driving under the influence, injury to persons or providing false information must be reported. The definition of conviction includes convictions following a plea of nolo contendere (no contest) as well as pleas or verdicts of guilty.
9. EXPEDITED APPLICATION FOR SPOUSES OR DOMESTIC PARTNERS OR ACTIVE DUTY MILITARY PERSONNEL
ARE YOU A SPOUSE OR DOMESTIC PARTNER OF ACTIVE DUTY MILITARY PERSONNEL?
If Yes, you may qualify for expedited application processing.*
*An applicant for expedited application processing must meet the following requirements: 1) provide evidence that the applicant is married to, or in a domestic partnership or other legal union with, an active duty member of the Armed Forces of the United States who is assigned to a duty station in California under official active duty orders and, 2) hold a current license in another state, district, or territory of the United States in veterinary medicine.
10. CERTIFICATION SIGNATURE AND DATE
I understand that I am required to report immediately to the California Veterinary Medical Board if I am convicted of any offense that occurs between the date of this application and the date that a California veterinary license is issued. I am also required to report to the California Veterinary Medical Board any disciplinary action and/or voluntary surrender against any license as a veterinarian or any veterinary related license that occurs between the date of this application and the date that a California veterinary license is issued. I understand that failure to do so may result in denial of this application or subsequent disciplinary action against my license.
I certify, under penalty of perjury under the laws of the State of California, that all information provided in connection with this application for licensure examination is true, correct, and complete. Providing false information or omitting required information is grounds for denial of licensure or revocation of licensure in California.
Signature of applicant_____________________________________________________________ Date__________________________
NOTE: All items in this application are mandatory; none are voluntary, unless indicated. Failure to provide any of the requested information will result in the application being deemed incomplete. The information provided will be used to determine qualification for examination and licensure, per Section 4841-4842 of the Business and Professions Code which authorizes the collection of this information. Information regarding the issuance or denial of a license by the Board may be transmitted to any other veterinary medical licensing authority. Candidates have the right to review their application subject to the provisions of the Information Practice Act. The Executive Officer is custodian of records.
INFORMATION COLLECTION, ACCESS, & DISCLOSURE: Information you provide on this application is maintained by the Executive Officer of the Veterinary Medical Board, 1747 N. Market Blvd., Suite 230, Sacramento, CA 95834. The information is requested pursuant to Business and Professions Code sections 4832-4844 and/or Title 16, California Code of Regulations, Division 20, Article 6.
FORM 25A-1 (Rev. 09/2010)