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Form 08-4251 - Application For Veterinary Technician Licensure - Department Of Community And Economic Development

VET

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

BOARD OF VETERINARY EXAMINERS

P.O. BOX 110806

JUNEAU, ALASKA 99811-0806

(907) 465-5470

E-mail: license@dced.state.ak.us

APPLICATION FOR VETERINARY TECHNICIAN LICENSURE

Appropriate fees must be included with this application.

Application Fee

$ 50.00

Examination Fee (if applicable)

$130.00

Initial License Fee

$ 60.00

This application must be filled out in full. If any section does not apply, please indicate this.

Name:

Mailing Address:

Telephone Number:

Social Security Number:

Date of Birth:

Height:

Weight:

EXAMINATION REQUIREMENT

Have you taken the Veterinary Technician National Examination sponsored by the American Veterinary Medical Association?

YES

If yes, date taken

Place

Your scores must be sent directly from Interstate Reporting Service to the board at the address above.

Do you wish to be scheduled for the next national exam administered in Alaska?

YES

EDUCATION

Have you graduated from a veterinary technician training program accredited by the American Veterinary Medical Association

YES

Dates of Attendance

Name and Location of School

Official transcripts must be sent directly from the institution to the board at the address above.

TRAINING

Have you completed two years of on-the-job training under the supervision of a licensed veterinarian? YES

Name of Employer

Address

Position Held

Dates

Name of Employer

Address

Position Held

Dates

The enclosed employment verification forms must be completed by the supervising veterinarian and must

be notarized.

-3-

08-4251 (Rev. 11/00)

Form 08-4251 - Application For Veterinary Technician Licensure - Department Of Community And Economic Development

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