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Form 08-4251 - Application For Veterinary Technician Licensure - Department Of Community And Economic Development Page 2

REFERENCES

List three references, at least two of which are licensed doctors of veterinary medicine, who have knowledge of your character

and professional abilities. These individuals must also provide notarized reference letters regarding your character and

professional abilities.

Name

Address

Name

Address

Name

Address

REGISTRATION DATA

Please list any other state or province in which you are licensed as a veterinary technician:

State

Registration Number

Date Issued

Current?

State

Registration Number

Date Issued

Current?

If any of the following answers are YES, explain fully in a separate letter and attach any legal documentation, if applicable.

YES

1. Has your professional license ever been revoked, suspended, surrendered, stipulated, or been subject

to any other restriction, censure, reprimand, or disciplinary action in any jurisdiction?............................

2. Have you been the subject of an unresolved complaint or disciplinary action before an authority regulating

the veterinary profession? ........................................................................................................................

3. Have you ever had a lawsuit filed against you alleging fraud or misrepresentation?...............................

4. Have you been convicted of any criminal offense other than a minor traffic violation?............................

5. Within the last five years, have you experienced or been treated for any mental or emotional illness which

may impair or interfere with your ability to practice as a veterinarian?.....................................................

6. Within the last five years, have you been addicted to or excessively or illegally used alcohol or a controlled

substance?...............................................................................................................................................

7. Have you experienced a physical disability which may impair or interfere with your ability to practice as

a veterinarian?..........................................................................................................................................

If granted registration, I will be governed by the rules and regulations for the Alaska State Board of Veterinary Examiners and

will, at all times, observe and abide by the Code of Ethics adopted by the board.

Signature of Applicant

Date

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for the State of

this

day of

, __

NOTARY PUBLIC

My Commission Expires:

-4-

08-4251 (Rev. 11/00)